1. eRX Enhancement Project Presentation for the EDM Forum June 7, 2014 San Diego, CA

2. Project Purpose Background: Using PBM generated data received by the Health Plan, over 700 PCPs are arrayed by the reported % eRx versus non-eRx codes. The data included more than 240,000 Rx over 12 month period More than 100 PCPs have more than 3000 Rx per year 50 PCPs had between 30% and 90% eRx 50 PCPs had below 2% eRx Analysis and intervention focused on providers with more than 3000 Rx and greater than or equal to 30% eRx volume 2

3. Project Goal: 1. Increase the use of eRx from current level to 90%: For those providers who already had an E-prescribing system, investigate methods of improvement from current levels 2. Decrease the number of non-formulary Rx: Assumes that the increased use of e-Rx would provide an automated formulary from the prescribing system 3. Decrease the number of Prior Authorization Rx requests: increased use of e-Rx would increase the use of formulary and reduce prior authorizations 3

4. Investigation Method Data Analysis: Using 2013 Health Plan generated data from Pharmacy Benefit Manager, analyst’s reviewed eRx levels, formulary compliance levels and costs for 50 PCPs 12 high volume PCPs were interviewed as a sample to determine office practice issues, technology and processes for eRX Requested and discussed the PCP’s Certified EMR, Meaningful Use report of eRx rates for the same 2013 period Interviewed high volume pharmacies onsite Discussed findings with Health Plan Prepared Training and Technical Assistance Materials 4

5. Analytical Findings Reviewing data of more than 240k Rx indicates NO correlation between eRx rates and formulary compliance or cost of Rx. Providers with low eRx were sometimes lower cost and higher formulary compliant and other times not. eRx rates were not impacted by the type of Electronic Health Record, e.g. no pattern of use by EHR type. Data portrayed eRx levels different from those found using the EHR eRx reporting tool for Meaningful Use: Provider 1: 89.02% vs. eRX EHR report of 98.83% Provider 2: 44.09% vs. eRX EHR report of 79.80% Provider 3: 56.01% vs. eRx EHR report of 99.25% 5

6. Pharmacy Findings Chains represent 60% of all pharmacy claims Among chains, Rite Aid, Walgreens and CVS represent 93% of all claims Data on eRx rates is provided using “origin codes” from Pharmacy 6

7. Top Chains: Rite Aid, Walgreens and CVS Analyzing the code of origin showed similar results except Walgreens “pharmacy dispensing” is 7-10x higher at 10.4%. Volume is on average 15,000/month with this origin code. Does this workflow/coding contribute to under-reporting eRX rates among providers? 7

8. Lessons From the Field: Provider Perspective Operational Findings – Provider Interviews Pharmacy doesn’t show up in EHR as eRX capable even if it is Medication not properly identified as formulary in EHR No formulary approval notification while eRx’ing No prior authorization link to health plan in EHR Providers carry pocket formulary due to lack of system capability and confidence Practice initiates eRX in EHR but pharmacy/ PBM fulfills manually Pharmacy prints first page only, but e-Rx had multiple pages Pharmacy “lost” eRx and patient is waiting Pharmacy will clarify formulary coverage with Health Plan and call back Pharmacy will obtain necessary Prior Auth from Health Plan Operational Findings – Provider Interviews Pharmacy doesn’t show up in EHR as eRX capable even if it is Medication not properly identified as formulary in EHR No formulary approval notification while eRx’ing No prior authorization link to health plan in EHR Providers carry pocket formulary due to lack of system capability and confidence Practice initiates eRX in EHR but pharmacy/ PBM fulfills manually Pharmacy prints first page only, but e-Rx had multiple pages Pharmacy “lost” eRx and patient is waiting Pharmacy will clarify formulary coverage with Health Plan and call back Pharmacy will obtain necessary Prior Auth from Health Plan 8

9. Lessons from the Field: Pharmacy Perspective Key Findings  Pharmacies interviewed varied widely in their process, training and use of origin codes which generated the data that was analyzed from the health plan  One pharmacy did not use the codes at all, one codes an eRx as call if there is a question including if it needs a prior authorization  Some reported problems with the eRx once it is received at the pharmacy, e.g. unclear what the drug is, the instructions don’t match the medication, the drug is not formulary for the health plan  The handling of prior authorizations for Non-Formulary Rx varied widely among the physicians including a lack of ability of obtaining the prior authorization while using the EHR.  The EHR’s eRx is not interfaced into the Pharmacy application and has to be copied into the Pharmacy system manually Key Findings  Pharmacies interviewed varied widely in their process, training and use of origin codes which generated the data that was analyzed from the health plan  One pharmacy did not use the codes at all, one codes an eRx as call if there is a question including if it needs a prior authorization  Some reported problems with the eRx once it is received at the pharmacy, e.g. unclear what the drug is, the instructions don’t match the medication, the drug is not formulary for the health plan  The handling of prior authorizations for Non-Formulary Rx varied widely among the physicians including a lack of ability of obtaining the prior authorization while using the EHR.  The EHR’s eRx is not interfaced into the Pharmacy application and has to be copied into the Pharmacy system manually 9

10. Area of Focus: Training for the Future 10 ISSUEIntervention Formulary not up to date on WebsiteHealthPlan increased interface timing with intermediary Formulary not in the EHR interfaceTeam worked with Surescripts to identify practice specific EHR upgrades Providers using pocket formulariesOnsite training to increase confidence post EHR upgrade Office relies on pharmacy to determine formulary Onsite training to increase confidence post EHR upgrade of and operational workflow improvements EHR does not produce correct eRx when it reaches the pharmacy Discussed interface issues with Surescripts and specific EHR vendor Pharmacy does not code correctly as eRx from provider Trained on site pharmacy techs on importance of correct codes Pharmacy must manually enter incorrect eRxIdentified high volume providers for training Pharmacy does not use or is poorly trained on their eRx processes and software Project funded on site training of eRx processing tools for specific High Volume pharmacies

11. Project Goal 2.0: 1. For those high volume providers who already had an E- prescribing system, investigate methods of improvement from current levels – whatever they may actually be! 2. Decrease the number of non-formulary Rx: Address: technology interface issues, EHR feature mistrust, training and process apathy. 3. Decrease the number of Prior Authorization (PA) Rx requests: Working with the health plan to identify key areas of Prior Authorization concerns with pharmacy and providers, develop a training process, refined PA requirements and technology enhancements to reduce the requests by provider. 4. Training and education of the high volume Pharmacies for workflow, coding and technology utilization. 11

12. Questions? 12