1. NYBGH Actionable Pharmacy Benefit Strategy for 2011 and Beyond
Jack E. Bruner, FSA Executive Vice President Strategic Development CVS Caremark
Best Practices in Medication Adherence
July 22, 2010

2. Agenda The Emerging Health Care Environment Why Adherence Matters
Why Non Adherence Happens
What Strategies are Employers Considering
Delivering Best-in-Class Adherence Results
Best-in-Class PBM Engagement
Best-in-Class Retail Engagement
Proactive Pharmacy Care – Consumer Engagement
Creating Breakthrough Adherence Results
30 day vs 90 day adherence
The Impact of PBM Mail Clinical Programs
Extending PBM Clinical Programs to Maintenance Choice
The Impact of Evidence Based Plan Design
Summary

3. The Emerging Health Care Environment
Health Reform
Expanded Coverage
Medicare
Comparative Effectiveness
Medical Home
Accountable Care Organizations
Bio Equivalents
CVS CAREMARK
MANDATORY
MAIL
COST SAVINGS
RETAIL
MEMBER EXPERIENCE
This visual shows the historic tradeoff between cost savings and member experience.
This tradeoff no longer applies as desired results on each dimension can now be achieved.
Clients all over the country, from different industries and with a variety of member population sizes are working with us to improve their savings and member experience.
Health Reform Expands Access, But Cost and Quality Breakthroughs Require Leadership

4. Why Adherence Matters: The Challenge and The Opportunity
Overall Chronic Disease: $1.3 Trillion1
Not adherent 18%
Adherent 17%
Cancer $319 billion
Diabetes $132 billion
Hypertension $312 billion
Heart Disease $169 billion
Mental disorders $217 billion
Adherent with Gaps in Therapy 20%
Diagnosed but not medicated 15%
Unaware of condition/ undiagnosed 30%
Chronic conditions drive health costs.
Nonadherence drives the cost of chronic conditions.
Chart
Undiagnosed: Accordant HRQ helps identify those who do not know they have chronic conditions
Not medicated: iScribe helps bridge the gap between diagnosis and start of therapy
Not adherent and adherent with gaps: Your biggest opportunity to improve health and reduce costs
Adherent: We help keep them there
The opportunity…improve adherence to improve health and reduce costs.
Chronic conditions drive 78% of overall health care costs. Adherence improves health and reduces costs.2
Chart. CVS Caremark BOB data for diabetes 1. Source 2. Centers for Disease Control and Prevention, 2003 Data. 4

5. The Value of Investing in Adherence: Heart Failure Study
49.9% of heart failure patients studied were not optimally adherent
Re-hospitalization rates of non-adherent heart failure patients is nearly twice that of adherent patients
Optimal adherence saves almost $40,000 per year
% Readmitted Within 12-Mos.
Annual Expense
Adherence Level
Annual Medical Costs
Adherence Level MPR Ranges:
High :
Moderate: 0.40 –<0.80
Low: <0.40
Data reflects relationship between adherence level and indicated metrics controlled for moderate prospective risk (PRG range: ).
Total cost of non-adherence in the U.S. health care system is estimated between $100 and $300 billion annually.
88% of heart failure patients in the Adherence to Drug Therapy program maintain optimal adherence.
Sources: CVS Caremark Analytic Consulting, CVS Caremark data combined with third-party references including the United States Census, Centers for Medicare and Medicaid Services (CMS) and the World Health Organization (WHO).

6. Thomson Reuters Value of Medication Adherence (VOMA) project
In January 2010 Thomson Reuters initiated the VOMA project, which was commissioned by CVS Caremark.
The project focuses on the impact of medication adherence on these metrics:
Net total annual healthcare costs (pharmaceutical, medical, and total healthcare costs)
Annual healthcare utilization (hospital, emergency department, and physician visits)
Annual worker productivity (absenteeism and short-term disability)
These outcomes will be examined among patients with at least one of the following conditions:
Asthma/COPD
Congestive heart failure
Diabetes
Dyslipidemia
Hypertension.

7. How Non-Adherence Happens
Compliance: Taking medication doses and refilling prescriptions on time 8 6 4 2 -2 -4
% of fills
# of days past due date
Scripts not refilled on time 5 10 15 12 14
Persistence: Staying on medication for the entire prescribed time period
% of scripts filled
Fill number
Scripts never refilled 20 40 60 80
100 1 2 3 4 5 6 7 8 9 10 11 12
Fewer than 40% of maintenance scripts are refilled on time.
31% of original maintenance scripts are never refilled. 7 7

8. Consumer Research: Consumers are Confused by The Health Care System
The health care system doesn’t make it easy for consumers to do the right thing.
They don’t know who can tell them how to save money
Providers involved with their health care are disconnected from one another.
Time demands to stay adherent create big challenges for many
Video clip here
Source: 2009 CVS Signature Services Study by Synovate

9. Why Non-Adherence Happens
Non-Persistent After First Fill Survey
Non-Persistent After 2+ Fills Survey
Unique targeted solutions and communications to influence plan participant behavior
Adherence to Drug Therapy
First-fill counseling at CVS/pharmacy
Outbound calls to participants who drop off therapy at retail and mail
Refill reminders and pick-up reminders when prescriptions are ready
Proactive messaging and personalized letter-based communications to those who fall below compliance standards
Participant support and plan design reinforcement
iBenefit messaging
Customer Care messaging
*Other includes: Didn’t need 5%; in hospital/nursing home 5%; changed drug stores 5%; changed medications 5%; went on vacation 4%; worried about side effects 3%; had samples 1%
45% of plan participants cite forgetfulness as a root cause of non-adherence.1
CVS Caremark Analytics & Outcomes, BCB analysis, primary consumer research using call center 8/23/07 – 9/13/07

10. Improving Medication Adherence
What is the status of these strategies to improve member adherence?
ADOPTING A 90-DAY BENEFIT WHICH IMPROVES MEDICATION ADHERENCE
OUTREACH TO PRESCRIBERS TO RESOLVE GAPS IN CARE
ADHERENCE COUNSELING ON THE FIRST FILL OF MEDICATION
REDUCED COPAYS FOR CERTAIN DRUG CLASSES, HEALTH MANAGEMENT PROGRAMS AND/OR TARGETED HIGH-RISK MEMBERS
THERAPY DROP-OFF OUTREACH TO MEMBERS AND PHYSICIANS
CDHP DESIGNS WITH PREVENTATIVE DRUG LIST COVERAGE
CURRENTLY USING
CONSIDERING FOR FUTURE
NO INTEREST
Source: 2010 Employer Benefit Planning Survey.

11. What Do Employers Want from Preferred Pharmacies?
2008 CVS Caremark Benefit Planning Survey 20 23 32 33 35 34 37 46 54 74 36 42 39 38 31 17 29 14 15 16 18 13 8 2 12 10 9 6 0%
20%
40%
60%
80%
100%
Added savings through OTC/supplies discounts
Access to retail clinic services
Counseling to improve adherence
Demonstrated adherence improvement
Pharmacy staff knows participants’ pharmacy benefits
Participant's complete drug history visible to pharmacist
Counseling on savings opportunities & pharmacy benefits
Pharmacy available within 5 miles
Highest generic or preferred brand use
Provide best discounts/lowest price
Percent Respondents
Employer Client Forum Breakout 3: (Channels/Choice) Guiding Participants to Lower Cost Pharmacy
What Do Employers Want From Preferred Pharmacies?
Slide 5
Last revised: 3/2/09
NEW
High Priority
Medium Priority
Low Priority
Not sure
Source: CVS Caremark Benefit Planning Survey, 2008.

12. Incentivized/Mandatory Mail
Evaluating Benefit Structure and Delivery Alternatives to Support Improved Adherence, Pricing, Clinical Support and Customer Satisfaction
30 Day Refill
90 Day Retail Benefit
90 Day Retail Network
Incentivized/Mandatory Mail
Maintenance Choice
Initial Adherence
Ongoing Adherence
Mail Pricing
50%
Clinical Support
Customer Satisfaction

13. Best in Class Strategies to Maximize Adherence
Promote 90 day supplies over 30 day supplies to drive higher adherence rates
90 day fills vs. 30 day fills reduce non-adherence by 40%
A 90 day supply option with face to face interaction can be even more effective in improving adherence
Leverage Clinical Programs through Preferred Pharmacies
First fill counseling, refill reminders and outreach programs are critical
Addressing both mail and retail consumers is critical
Implement evidence-based plan design to incent members to stay adherent
EBPD improves adherence most among those with poorest adherence rates
Compliance based and reduced cost sharing vs free may drive ROI
Pie chart with channels -- SHOW # OF INDIVIDUALS IN RETAIL, MAIL, AND MAINTENANCE CHOICE, SPECIALTY AND IMPROVEMENT IN ADHERENCE FOR THOSE IN 90 DAY SUPPLY PROGRAMS
PLUG IN CLIENT-SPECIFIC #S TO SHOW PRESENT STATE & OPPORTUNITY IN EACH CHANNEL
MAINT CHOICE AND MAIL IMPROVE ADHERENCE
GENERAL STORY LINE:
CHOOSE THE CHANNEL
CHOOSE THE PLAN DESIGN
IMPROVE ADHERENCE
Best-in-Class clients maximize adherence through a multi-faceted and comprehensive approach. 13

14. Pfizer 30 vs. 90 Day Case Study Member Profile with Adherence Gaps
Key findings
The above identifies a Pfizer member taking Lipitor 10 mg
This member started 30-day therapy on December 2008
In August 2009, they changed to 90-day therapy
The chart shows the decrease in medication days on hand as the member approaches his or her next refill date
When a member is on 30-day therapy, there is more potential for gaps in care between fills
Maria: Review this slide with the key points being:
Actual Pfizer colleague
shorter days supply leads to more gaps in medication regimen
Adherence improved as 90 days supply therapy was initiated.

15. Member Profile with Minimal Adherence Gaps
Note: Member profile based on Pfizer member. Adherence bands are Pfizer specific, but exclude Pharmacia and Wyeth populations.
Maria: Identify how adherence is maintained as a Pfizer colleague is continually using 90 days supply. 90 days supplies not only improve adherence but they also help to maintain it.
Key point: Refer to the small table that identifies adherence band by percent 90 days usage.
Key findings
This is a Pfizer member profile taking Lipitor 10 mg; they started 90-day therapy in mid January 2009
The gaps in therapy is minimal with their 90-day therapy
Your data shows that as the percent of 90-day usage increases, adherence increases
Further, mail service and Retail-90 pricing options provide more aggressive financial arrangements

16. Lay Person or Nurse Call Nurse/Doctor/Pharmacist
Careful Review of the Medical Literature: What Works in Pharmacy Health Care
Pharmacist Intervention Is Superior to Other Adherence Efforts
COHEN’S D STATISTIC REVEALS RELATIVE STRENGTH OF INTERVENTIONS IN META-ANALYSIS OF OVER 300 PUBLISHED STUDIES
Lay Person or Nurse Call
Pharmacist
Call
Lay Person
at Home
Nurse or Doctor
at work-site
Pharmacist
at Pharmacy
Nurse/Doctor/Pharmacist
at Clinic
Nurse/ Pharmacist
at Hospital
Source: Cutrona et al, Modes of delivery for interventions to improve cardiovascular medication adherence. Submitted for publication. CVS Caremark Harvard Adherence Partnership,  

17. Our Consumer Engagement Engine in Action: Personalized Opportunities for Helen
Wednesday, April 19, 2017
Identifies Opportunities
Prioritizes
Opportunities
IDs Most Effective Communication Mode
Generic
Preferred
OTCs
Mail Pharmacy
New Rx
Lapsed Rx
Therapy Gap
Safety
Automatic Refill
Health Plan Messages
New Rx
Generic
Lapsed Rx 1 2 3
Mail
Pharmacy
Text
Inbound IVR
Customer Care
Outbound IVR
MD Communication
Consumer Engagement
Engine
Our Consumer Engagement, unique technology from CVS Caremark, is a tool used by our pharmacy professionals to guide our interactions with your members.
The engine (red box) is informed by evidence-based medicine, your plan designs, your members’ drug histories, and key data from our Behavioral Analytics and Outcomes group.
It scans opportunities for the member, chooses the top opportunities, and selects (based on our research and member preferences) the communications channels that will be most effective for presenting the opportunities. The result of each member interaction is then captured back in the engine for future reference.
We will also be able to drive your health plan messaging (e.g, encouraging DM enrollment) at all touchpoints through the consumer engagement engine.
Evidence-Based Medicine
Plan Design
Personal Drug History
Behavioral Analytics and Outcomes
“Let’s make that change.”
DATA ON ACTUAL BEHAVIOR
SAVINGS AND HEALTH OPPORTUNITIES FOR HELEN, NEWLY DIAGNOSED WITH DIABETES
Patient story is represented for illustrative purposes only. Any resemblance to an actual individual is coincidental. All data sharing complies with applicable firewall and privacy laws. 17 17

18. Days’ Supply Dramatically Affects Adherence
Comparison of annual adherence: 30-day vs. 90-day supplies
80% MPR
Annual MPR
Name of deck: 2009 CVS Caremark Consultant Forum
Name of slide: Daus Supply Dramatically Affects Adherence
Slide#: 26
Date revised: 4/23/09
Project:
Notes:
1) MPRs were calculated using 2007 data for patients whose initial 2007 RX was in the first quarter of 2007 using claims from the remainder of 2007.
2) A random sample of 5% of members were selected from the BOB.
Source: Analytic Core Services, 2009. 18

19. MPR Comparison 90-Day Retail vs. Mail
MPR1 for Initiators2 from a 5% BOB Sample3 by Drug Class
Name of deck: 2009 CVS Caremark Consultant Forum
Name of slide: MPR Comparison 90-day Retail vs. Mail
Slide #: 29
Date revised: 4/23/09
90-day Retail
90-day Mail
Adherence at mail is systematically higher than among 90-day retail programs
1) MPRs were calculated using 2007 data for patients whose initial 2007 RX was in the first quarter of 2007 using claims from the remainder of 2007.
2) Initiators did not have a claim for a drug within the indicated class in the last six months of 2006
3) A random sample of 5% of members were selected from the BOB.
Source: CVS Caremark Analytics and Outcomes, 2009. 19

20. 30% MORE USERS STILL ON THERAPY WHEN THEY HAVE A CHOICE OF ACCESS
Retail/Mail Choice Increases Adherence, While Also Driving Low Cost Solutions
Maintenance Choice Improves Adherence Compared to Mandatory Mail
1000 People Starting Statin Therapy
1000
1000
1000
MAINTENANCE CHOICE
MANDATORY/INCENTIVIZED MAIL
30% MORE USERS STILL ON THERAPY WHEN THEY HAVE A CHOICE OF ACCESS
1 IN 3 DROP OFF BEFORE 1ST REFILL
750
730
720
NEARLY HALF NEVER MAKE IT TO MANDATORY MAIL
580
500
520
470
Update source statement to: CVS Caremark Enterprise Analytics study of adherence in Maintenance Choice, R297, 2009.
Note that there have been questions about this slide, specifically about the metrics and the comment on the 40-days data. The metrics show that 72-73% remain on therapy, equivalent to 1 in 4 dropping off therapy. Yet the comment states that 1 in 3 drop off therapy before the 1st refill. Both statements are correct. In this particular study for Statin therapy we see 1 in 4 drop off. Yet on average in our data across all therapies, we see 67.7% ffrp, or 1 in 3 dropping off. 1 in 3 is also a general industry number.
Notes from the Marketing deck using this slide:
This slide represents a breakthrough finding: more people stay on therapy when they have a choice of access. The chart compares what happens when 100 members with diabetes started a new statin therapy. One group (orange) is on mandatory mail and the other (blue) is on Maintenance Choice.
1 in 3 drop off before the first refill. At 90 days, nearly half have dropped off. The transition to mail pharmacy is an obstacle some never overcome.
And at 180 days, there are 30% more Maintenance Choice members still on therapy than those on mandatory mail. In short, more of your members are likely to be adherent when they have the choice of mail delivery of CVS/pharmacy pick-up.
360
250
DAY 1
40 DAYS
90 DAYS
180 DAYS
No Surprise: Choice Improves Adherence!
Source: CVS Caremark Enterprise Analytics study of adherence in Maintenance Choice, 2009.

21. Maintenance Choice vs. Mail: A More Personalized Consumer Experience
MPR1 rates for 90-Day Starts2 by Maintenance Class3 and Delivery Channel
Name of deck: 2009 CVS Caremark Consultant Forum
Name of slide: MPR Comparison Maintenance Choice vs. Mail
Slide#: 30
Date revised: 4/23/09
Project:
Notes:
MPR was calculated from the date of the a patient’s first RX within a maintenance class for the following 180-day period, truncating MPR at 1 for those where the sum of days exceeded 180.
90-day Starts included initiators and those patients who had not received a 90-day RX in the 180 day period preceding their first RX within a maintenance class
Maintenance classes were any GPI4 class where 75% or more of the claims were listed as maintenance medications, these classes accounted for 99.1% of all claims designated as maintenance class
Results represent the experience from a pilot client’s patients, individual maintenance classes had sample sizes ranging from around ten to 50, with most around 30. 21
Source: CVS Caremark Analytics and Outcomes, 2009. 21

22. 90-Day Mail Pricing Case Study
67K-life client wants to maintain mandatory mail savings and increase member satisfaction
Client chose 90-day mail pricing mandatory plan design, Maintenance Choice®
Members gained access to 90-day mail pricing at CVS/pharmacy
Members received letters to make transition
Twelve months post implementation, 84% of eligible maintenance utilization filled at 90-day mail pricing while improving member satisfaction*
Adherence increased up to 5%; members that are optimally adherent increased up to 7%
Client Need
Solution
Maintenance Choice Case Study
Title: 90-Day Mail Pricing Case Study
Slide: 1
Project #: 19998
Approved: 3/4/10
Client Background:
Implemented Maintenance Choice on 1/1/09 on top of previously implemented Mandatory Mail
Penalty stayed the same as it was under Mandatory Mail  mail copay for 30-day supply; incurred after two, 30-day fills at any retail pharmacy
90% of members have Maintenance Choice. Remaining population part of a union group and have CVS90.
Client testimonial: This is a great program for us, especially because of the nature of our population that is always traveling. This offered us an alternative while still allowing for the savings from a mandatory 90 day fill program.
Note: Previous mandatory mail to Maintenance Choice clients do not receive phone calls as part of the proactive communication process.
Results
“Through Maintenance Choice, our members can enjoy the flexibility of picking up their medications at a local CVS/pharmacy.1”
*Based on days supply. Data represents non-specialty maintenance drugs.
The Maintenance Choice program is available to self-funded employer clients that are subject to ERISA.  Non-ERISA plans such as insured health plans, plans for city, state or government employees, and church plans need CVS Caremark Legal's approval prior to offering the Maintenance Choice program. Source: CVS Caremark Analytic Consulting Services data, February CVS Caremark employer client testimonial, December 2009.
19998

23. Behavior Change Moving from Mandatory Mail to Maintenance Choice®
Delivery Channel of Maintenance Medications (% of Days’ Supply)
CVS 90-DAY SUPPLY
MAIL 90-DAY SUPPLY
RETAIL 30-DAY SUPPLY
Q4 2008
Q1 2009
Q2 2009
Q3 2009
Q4 2009
51.5%
42.9%
16.6%
17.4%
37.3%
34.1%
16.3%
81.0%
19.0%
31.8%
39.7%
46.0%
16.7%
49.6%
Maintenance Choice Case Study
Title: Behavior Change Moving from Mandatory Mail to Maintenance Choice
Slide: 2
Project #: 19998
Approved: 3/4/10
Note: this data includes only Maintenance Choice claims and not those for union members using CVS90 program.
*Data represents non-specialty claims
“I travel frequently and would much rather pick-up my medications at a pharmacy. I also like the automatic refill option. 1”
Source: CVS Caremark Analytic Consulting Services data, February CVS Caremark Member Survey, Spring 2009.
19998

24. Choice of Access Drives Optimal Adherence
Drug Category
Average MPR 2008
Average MPR 2009
% Increase in MPR
% Optimally Adherent 2008
% Optimally Adherent 2009
% Increase Optimally Adherent
Diabetes
76.6%
79.2%
3.4%
57.2%
61.7%
7.8%
Cholesterol
80.2%
80.3%
0.1%
64.6%
65.2%
1.1%
Asthma
67.6%
71.3%
5.5%
46.9%
50.0%
6.6%
Hypertension
81.6%
84.3%
3.3%
68.6%
73.3%
6.9%
Maintenance Choice Case Study
Title: Choice of Access Drives Optimal Adherence
Slide: 3
Project #: 19998
Approved: 3/4/10
“Another convenient way for members to purchase prescriptions at an affordable price and maintains compliance with therapy.2”
*Optimal adherence is defined as MPR ≥ 80 percent.
Source: CVS Caremark Analytic Consulting Services data, February CVS Caremark employer client testimonial, December 2009.
19998

25. Engagement Changes Behavior: Targeted Adherence Outreach
Challenge
Close to 70% of plan participants prescribed a chronic maintenance medication will discontinue taking it within the first year1
Solution
Clinical interventions throughout the treatment cycle of participants on maintenance medications with the right tactics to engage each plan participant
Welcome letter
Adherence survey
IVR and Web: automated refill reminders, renewals, pick-up prompts
Face-to-face non-adherence counseling at CVS Retail
Local CVS pharmacist outreach calls to participants identified as potentially non-adherent
Personalized therapy drop-off letters to plan participant and provider
Result: 35 percent of plan participants chose to restart therapy as a result of Adherence Outreach2

26. Achieving Adherence Results with Proactive Pharmacy Care™
Adherence of Participant Group vs. Control Group1 0%
20%
40%
60%
80%
100%
Diabetes
Hypertension
High Cholesterol
Heart Failure
Respiratory
14.4%
2.3%
3.0%
4.1%
15.5%
5.8%
5.2%
16.9%
2.8%
3.4%
24.8%
7.8%
3.8%
25.0%
10.4% * +
*Statistically significant after adjusting for age, gender, health status, and mail use. + Measurable, but not statistically significant.
Non-Adherence to Adherence
Maintaining Adherence
MPR
Program Impact
Proactive quality care prevents lapses in therapy, achieving 25% higher adherence.
1. CVS Caremark A&O Evaluation of ATC Impact, 2008. 26

27. Comprehensive Adherence Support Across Care Continuum
Results
Challenge
Capabilities
Up to 60% of new prescriptions are never filled1
Pick-up reminders
Electronic prescribing
Pick-up rate increased up to 30%6
First-fill counseling
Refill reminders
Welcome letter
90-day supply assistance
Self injection training at MinuteClinic
1 in 3 stop therapy before first refill2
Reduced drop-off by 5% to 10%
Therapy drop-off and noncompliance letters
Copay incentives
Physician messages
Automatic refill and renewals
Face-to-face counseling
Personalized pharmacist calls
Specialty CareTeam calls
50% restarted therapy8
Improves adherence by 14-25%9
Up to 70% stop therapy within first year3; 50% are inconsistent with therapy4
Fincham, Jack E. Taking Your Medicine: A Guide to Medication Regimens and Compliance for Patients and Caregivers. 2005, p 16.
Caremark data combined with third-party references, including the United States Census, Centers for Medicare and Medicaid Services, ICMS, the World Health Organization (WHO), among others.
CVS Caremark data, 2007.
Fincham, Jack E. Taking Your Medicine: A Guide to Medication Regimens and Compliance for Patients and Caregivers. 2005, 17.
NEJM, “The Quality of Health Care Delivered to Adults in the U.S.,” 348: ,2003.
CVS Caremark estimate, 2009.
CVS First-Fill Counseling data, Current average of 15% drop-off reduction; however, First-Fill Counseling is currently targeting a limited number of participants (35%). Conservative internal estimates for drop-off reductions after full implementation of First-Fill Counseling are 30%.
CVS Caremark data, 2008
CVS Caremark A & O Evaluation of ATC Impact, 2008.
Literature-based savings model.
First fill counseling can deliver reduced drop off rates from 15-30%. Currently, first fill is limited to targeting only 35% of prescriptions and will be expanded to 100% of the opportunities in Part of this is due to the manual process we have in place. However, as this becomes automated next year and begins to take advantage of all the opportunities we expect to see up to 30% reduced drop off.
Face-to-face physician consultation
Screenings at MinuteClinic
Physician messaging
Participant health reports
Beginning statin therapy after a heart attack saves $120 per participant10
44% have gaps in care5 27

28. Case Study: Best Practices in Evidence Based Plan Design
12,800 life employer wanted to increase employee adherence to drug therapy in several disease states
Balance ROI – pharmacy cost increase vs. overall medical savings
Client Need
Client implemented Evidence-Based/Value-Based plan 7/1/07
Reduced member cost share to first tier copay within Asthma/COPD, Oral Diabetes, Insulin and ARB drug classes
Members received phone calls and letters to transition, remain adherent
Solution
17.4% reduction in Emergency Room visits for pilot group
Reduced hospitalizations – down 1%
Direct costs declined 28.4%
Impact on overall health care trend
Pilot group (members with asthma, diabetes, COPD, etc.) trend was 2.2% lower than the overall group (all members)
Solution:
Communication Plan
Initial letter mailing in 2007
Follow-up education for sustained adherence results: reminder letters sent to all eligible members in January 2008, January 2009 and July 2009
Prioritized subsets of members to better target outbound calls
Reminded health specialists to discuss this benefit with members during counseling
Results:
17.4% reduction in Emergency Room visits for this group
(28.7 visits per thousand to 23.7 visits per thousand)
Reduced hospitalizations: Down 1%
(144.5 admits per thousand to admits per thousand)
Direct costs declined 28.4%
(89.28 PMPM to PMPM)
Impact on overall health care trend
Pilot group (people with asthma, diabetes, COPD, etc.) trend was 2.2% lower than the overall group (all BlueChoice members)
Deck: Content reformatted from AHIP Fall 2009 Jack Bruner/Dr. L. Long “Maximizing Adherence, Outcomes and Value by Removing Cost Barriers to Care”
Title: Maximizing Adherence, Outcomes and Value by Removing Cost Barriers to Care
Slide #: 9-13 EBPD Case Study
Project #:
Approved:
Results
Source: Client-reported data October 2009.

29. Pharmacy Adherence Results
Case Study: Average MPR by Class
75%
78%
73%
76%
75%
75%
75%
67%
61%
PERCENT OF POPULATION
58%
53%
50%
50%
47%
44%
44%
40%
40%
40%
35%
Deck: Content reformatted from AHIP Fall 2009 Jack Bruner/Dr. L. Long “Maximizing Adherence, Outcomes and Value by Removing Cost Barriers to Care”
Title: Maximizing Adherence, Outcomes and Value by Removing Cost Barriers to Care
Slide #: 9-13 EBPD Case Study
Project #:
Approved:
INSULIN
ASTHMA/COPD
Oral Diabetes
ARBs
Jan-Jun 07
Jul-Dec 07
Jan-Jun 08
Jul-Dec 08
Jan-Jun 09
Sustained improved adherence in key chronic conditions.

30. EBPD Effectively Increases Adherence
73.4%
8.4%
-4.5%
42.8%
-1.2%
-6.3%
32.4%
-3.5%
-12.1%
Relative Improvement in MPR by Baseline Adherence Category
-20% 0%
20%
40%
60%
80%
Poor: MPR<60%
Moderate: MPR 60%-80%
Optimal: MRP > 80%
Compliance-based EBPD
Therapy- based EBPD
BoB Benchmark
An average client’s adherence strategy improves adherence 32% among those with poorest adherence rates
EBPD improves adherence 73% among the same group
Study Populations
EBPD participants from 5 clients
Compared to a random sample of BoB participant, accounting to various other similar initiatives
Study Periods
12 months prior to EBPD (2007)
12 months after EBPD (2008)
Name of deck: 2009 CVS Caremark Consultant Forum
Name of slide: EBOD Implementation Evaluation Study
Slide #: 32
Date revised: 4/23/09
Project:
Greater adherence improvements
in populations with low baseline adherence.
Source: CVS Caremark A&O Evaluation of EBPD Impact, 2009. 30

31. Pharmacy Advisor™: How It Works
Identify members who can benefit
Outreach to engage and motivate (Mail, Phone, Face-to-Face)
Member Counseling (Mail, Phone, Face-to-Face) – Prescriber engagement if needed
Monitor and Follow-up
Report
Deck: Improving Savings and the Member Experience with Pharmacy Advisor
Slide 3
Last reviewed: 3/10
Project 19990d
How we do it:
We identify members who have diabetes and are age 18 or older
We reach out to members to engage and motivate them
Inbound access to and live outbound personalized phone calls from the Pharmacy Advisor Team
Face-to-face counseling at CVS/pharmacy
Mailings and IVR
We provide personalized consultation to members and physicians
Interventions to improve adherence and close gaps in care
Referrals to clients’ disease management programs as appropriate
We monitor adherence and provide follow-up as necessary
We report results back to clients
We offer what no one else can: consistent and coordinated member experience across all channels
Coordinated outreach made possible by the CEE
Once we have a patient’s attention, we can drive optimal impact through our touch points
CVS pharmacists will provide timely and comprehensive counseling to address opportunities to improve adherence and close gaps in care
Engage physicians as appropriate
Inform members of their retail to mail benefit
Provide referrals to clients’ existing disease management programs as appropriate
The Pharmacy Advisor Team is staffed by highly trained pharmacists, pharmacy technicians and call center representatives who are trained on the unique aspects of diabetes and supporting our diabetic members
Informational resource for members participating in the program
Able to address clinical opportunities related to gaps in care and adherence
Help manage cost by providing counseling on generics and lowest cost channels 31

32. Pharmacy Advisor: Managing Diabetes – Multiple Channel Communication
OTHER PBMs
CVS CAREMARK
Diabetic Member Experience
Diabetic Services Needed
What Do I Need to Know?
How to Get Started
My Diabetes Medications
Importance of Blood Glucose Monitoring
Recommended ADA Exams and Labs
Member Resources
Diabetes Care Kit
First-Fill Adherence Counseling
Gaps in Care and Adherence Counseling
Phone, Letters and Web
Face-to-Face
Patient Education and Support
Diabetes Advocate
MinuteClinic®
How Can I Afford All of This?
Prescription Savings Opportunities
Blood Glucose Monitor Programs
Diabetes Supplies and OTCs
Exams and Lab Tests
Multi-Channel Savings Counseling
Copay Wavier, Generic and Mail Savings
Phone, Letter and Web
Face-to-Face
Referral to Free Meter Programs
20% ExtraCare® Health Savings
Affordable, Convenient MinuteClinic Visits
This is just one example of our clinical difference in action.
On the left you’re looking at the key questions members with diabetes ask. As you can see, they’re looking for expert guidance. In the middle are a list of services that are needed to meet their needs. Over on the right, the red dots indicate what CVS Caremark provides vs. what other PBMs provide.
Other condition management programs such as XYZ will be packaged like you see here and made available in 2011.
Who Can Help Me Stay on Track?
Pharmacist
Diabetes Advocates
Physicians
DM Program/Health Advocate Support
Nurse Practitioners
Fully Informed Interactions
Full View of Patient History Care Needs
Pharmacist/Physician Coordination
Integrated Health Messaging/Data Exchange
MinuteClinic Exam and Lab Data Sharing

33. Pharmacy Advisor™: Higher Member Engagementf
Pharmacy Advisor™: Higher Member Engagement
% Targeted Members Engaged1
We reached and engaged more targeted members with diabetes
74%
47%
Disease Management Average
Deck: Improving Savings and the Member Experience with Pharmacy Advisor
Slide 7
Last reviewed: 3/10
Project 19990d
Through the Pharmacy Advisor program, we leverage our relationship with members to engage them on clinically relevant medication counseling. Through our channels (using both the Pharmacy Advisors team by phone and CVS pharmacists in store), we are able to reach and counsel a significant portion of members. The Pharmacy Advisor program can complement the client’s own Disease Management offerings by dramatically extending reach to your members, much beyond what average DM vendors typically achieve.
Phone Advisors
Face-to-Face Advisors
Source: Cutrona et al, Modes of delivery for interventions to improve cardiovascular medication adherence. Submitted for publication. CVS Caremark Harvard Adherence Partnership, 2009.

34. After 3 Months: More Gaps Closed
Phone Advisors
Face-to-Face Advisors 20 25 14 14
PILOT
+98%
+59%
GAPS CLOSED
GAPS CLOSED
CONTROL
Deck: Improving Savings and the Member Experience with Pharmacy Advisor
Slide 8
Last reviewed: 3/10
Project 19990d
The early results of our pilot have been dramatic. When we look at the impact our targeted counseling sessions are producing, we see that we are closing gaps between 60% and 100% faster than a control group. Our face to face Advisors are closing nearly a quarter of all gaps that existed at the start of the pilot. Closing gaps in care improves the health of the client’s diabetics and can yield lower healthcare costs over time.
PILOT WEEKS
PILOT WEEKS
Gap closure will continue to improve over time.
Note: Condition Management pilot results for pilot participants in defined pilot region
Source: A&O gap closure data 34 34 34

35. Incentivized/ Mandatory Mail
Evaluating Benefit Structure and Delivery Alternatives to Support Improved Adherence, Pricing, Clinical Support and Customer Satisfaction
30 Day Refill
90 Day Retail Benefit
90 Day Retail Network
Incentivized/ Mandatory Mail
Maintenance Choice
Initial Adherence
Ongoing Adherence
Mail Pricing
50%
Clinical Support
Customer Satisfaction

36. In Summary
Poor adherence to medication results in tragic economic and human consequences that drive healthcare cost.
CVS Caremark has created the first six sigma approach to analyze root causes and implement counter measures across channels.
The key to success is an integrated process of improvements in pharmacist counseling, convenience, access, communication and plan design.
We are anxious to work with you to reduce overall healthcare costs by improving adherence health outcomes.
Pie chart with channels -- SHOW # OF INDIVIDUALS IN RETAIL, MAIL, AND MAINTENANCE CHOICE, SPECIALTY AND IMPROVEMENT IN ADHERENCE FOR THOSE IN 90 DAY SUPPLY PROGRAMS
PLUG IN CLIENT-SPECIFIC #S TO SHOW PRESENT STATE & OPPORTUNITY IN EACH CHANNEL
MAINT CHOICE AND MAIL IMPROVE ADHERENCE
GENERAL STORY LINE:
CHOOSE THE CHANNEL
CHOOSE THE PLAN DESIGN
IMPROVE ADHERENCE
The most significant opportunity to improve health outcomes and deliver health and productivity savings is improved adherence. 36