1. Drug Management Updates
September 27, 2017
MA Medical Directors Meeting

2. Drug Management Initiatives
Goal: Harvard Pilgrim is committed to using our customers’ claims dollars wisely while making sure our members have access to safe and effective medications 
New specialty drug vendor: CVS Specialty (7/1/17)
Medical drug management program: CVS Health Novologix (July – August 2017)
MedImpact Direct Mail (10/1/17)
2018 Premium formulary (1/1/18)
Innovative outcomes-based contracts with pharmaceutical companies

3. New Specialty Pharmacy Vendor
CVS Specialty
 5000 members
Successfully implemented on 07/01/2017
Allows us to consolidate from multiple vendors (Accredo, Magellan and Walgreens Specialty) to one and helps us achieve significant cost savings
What ?
Who ?
When ?
Why ?

4. MedImpact Direct Mail – Mail Order Program
 30,000 members
10/01/2017
- Improved Customer Service
- Cost Savings Opportunity
What ?
Who ?
When ?
Why ?

5. MedImpact Direct Mail – Mail Order Program
MedImpact has been our PBM since 2000
Confident that MedImpact Direct Mail will be an excellent mail service partner as they understand our membership and the level of service we expect
MedImpact Direct Mail will be the member’s single source for all mail order needs
NoviXus Pharmacy Services for dispensing
Orders can be placed by phone, mail or e-prescribing
Active prescriptions at Walgreens Mail will be transferred
Communication Timeline:
Employer and broker communications sent - week of July 17th
MedImpact sent member notifications - July 19th to July 28th
Providers were updated via Network Matters – August

6. Premium Formulary 2018 Redesigned Premium formulary
All members that currently have Premium formulary
January 1, 2018, regardless of anniversary date
To offer a more cost-competitive formulary
What ?
Who ?
When ?
Why ?

7. Premium Formulary Redesign
What's included
All FDA approved drugs within most classes
Generics
Most single source brands (i.e. no generic equivalent)
What's excluded
Non-FDA approved drugs
Drugs for cosmetic use only
Multi-source brands
High cost/Low value
Select drugs with OTC equivalents
Drugs used for cosmetic use only
New-to- Market Drugs
Included automatically
Excluded pending P&T Review
Plan Options
3-Tier
4-Tier

8. 2018 Premium Key Differences
Different from current Premium formulary
Excluding 895 drugs
828 are multisource brands = generic alternative available
67 additional drugs
Select Strategic Exclusions
High dollar/Low value
Support preferred drugs
Select drugs with OTC alternatives
Exclude new-to-market (NTM) drugs until reviewed for coverage
Different from Value formulary
Tier structure
Not sold on Exchange = not required to meet EHB benchmark plan compliance
Excluded drugs may differ

9. 2018 Premium Communication and Transition Plan
April
Brokers, employers, and providers notified
October
Early – subscribers
Late – Impacted members
1/1/18- 3/31/18
Transition
August
Mailing of ANOCs – starting week of 9/11, continue through week of 10/18
Impacted member letters tentatively scheduled to start week of 10/23
Formulary Changes Finalized
30-day supply
Disruption Report process available

10. Innovative Outcomes-Based Contracts
Mission
Pay for value Align payment for drugs with clinical benefit Assess the effectiveness of drugs in the real world setting and account for any variances with financial incentives/disincentives Effective and appropriate use of health care services while challenging manufacturers to demonstrate value
Goal
Process
Result

11. Recent Outcomes-Based Contracts
Manufacturer
Drug
Use
Details
Amgen Inc.
Enbrel
Autoimmune disease drug for rheumatoid arthritis
Focuses on positive clinical results when compliant with the drug
Repatha
PCSK9 inhibitor class to treat high cholesterol
Pay less if drug is less effective than shown in clinical trials
Full reimbursement for plan when a patient has a cardiovascular event when on therapy
Astra Zeneca
Bydureon
Improves blood glucose levels in type 2 diabetes
Focuses on getting patients to HbA1c goal
Brilinta
Anti-platelet drug to treat acute coronary syndrome
Protection from repeat hospitalizations in patients on drug compared to standard of care options

12. Recent Outcomes-Based Contracts
Manufacturer
Drug
Use
Details
Biogen
Avonex
Tecfidera
Tysabri
Multiple Sclerosis
Reduced cost for inferior annual relapse rate for Biogen products when compared to clinical trial rates
Eli Lilly and Company
Trulicity
Improves blood glucose levels in type 2 diabetes
Payment tied to success of lowering HbA1c compared to other agents
Forteo
For treatment of osteoporosis
Improved pricing with increased adherence rates
Novartis
Entresto
For the treatment of congestive heart failure
Guarantees a decrease in the rate of hospitalizations