BD Training

Biologics & Specialty DrugsThe Road to Sustainability

Mark Rolnick

Director, Pharmaceutical Benefits

Private Drug PlanCost Drivers

• Demographics• Mark-Ups and Fees• Coupon Cards• Lack of consumerism• Open formularies• Biologics & Specialty

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$Source: Canadian Institute for Health Information, Drug Expenditures in Canada, 1985-2009

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• Specialty Drugs make up 14 of our top 50 DINs

• 42 drugs on the Prior Auth DIN List & others in top 50

= $203.5 Million in 2011 up from 170 million in 2010

(+20.4%)

• 15.2% of PDD spend in 2011 vs. 13.2% in 2010

• Treating just ~1% of plan members

(Source: 2011/2010 SLF Book of Business for All claims)

Background Stats

Claimants over $25,000 in Spend

Source: Telus Health Solutions Data, March 2012

Unprecedented Growth

Source: Telus 2011 SLF All Claims Data report Telus PA DIN List (includes oral Cancer DINs)

Average Specialty Claim for drugs on the SLF

Prior Auth List = $2,340.80

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Sun Life’s Biologic Response Modifier Experience

• Top 3 biologics

• Distribution for utilization spans across age groups

–Reflective of multiple indications for these products

–Most common uses arthritis, gastrointestinal, psoriasis

DRUG NAME 2010 PAID AMOUNT 2011 PAID AMOUNT Growth #1 Remicade $40,265,975.64 $49,446,191.39 22.80%

#2 Humira $22,830,723.99 $29,109,898.38 27.50%#3 Enbrel $25,019,369.74 $26,781,645.93 7.04%

$88,116,069.37 $105,337,735.70 19.54%

(Source: 2011/2010 SLF Book of Business for All claims)

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Sun Life’s OncologyExperience

• Important Drugs

• Not a huge cost burden yet

• Growing incredibly quickly

Cancer Drugs 2010 PAID AMOUNT 2011 PAID AMOUNT Growth #1 Neulasta $7,058,323.15 $9,010,366.86 27.66%#2 Gleevec $5,760,711.53 $5,831,073.40 1.22%#3 Revlimid $3,504,050.32 $4,411,328.94 25.89%#4 Sutent $2,634,024.91 $3,185,328.66 20.93%

$18,957,109.91 $22,438,097.86 18.36%

Source: Trusheim et al.: Do Biologics Differ from Small Molecules? Forum for Health Economics & Policy, Vol. 13 [2010], Iss. 1, Art. 4

Biologics Percentage of Global Therapeutic Pipeline

8 in 10 agree“that rising costs will make it difficult to maintain Canada’s healthcare system” and that “Canadian healthcare faces a funding crisis”

7 in 10 agree“that rising costs and growing use of prescription drugs will make it difficult for employers to maintain their current drug coverage”

Awareness of Cost Pressures

What’s Your Drug Plan Philosophy?

• Is the Drug Plan a cost or an investment?

• Is it a benefit to employees? • Or is it Health Insurance?• Can Wellness & Drug

programs work together to limit disability claims?

Where does the Employers Responsibility begin and end?

Antibiotic for Acute chest infection? Cholesterol / Blood Pressure drugs prevent heart attack

in 15 years? Cancer drug that extends life by 3 mos? Biologic for Crohn’s, MS, Arthritis,

that helps keep members at work?

• Genetic testing shows, 25% chance at getting cancer in the next 10 years? Vaccine that costs $25,000 but prevents Alzheimer’s disease 30 years

from now?

What is the Employee’s role?

• How can they help keep Costs down? • Do they even know that its an issue?• How can we engage

them more?• What education can we

provide them?

What does the future hold in terms of specialty management?

• Negotiated reimbursement for high cost drugs where alternatives exist

• Risk Sharing arrangements for expensive therapies

• Maximums to avoid concerns of dose escalation

• Relying more on pharma company financial assistance

What does the future hold in terms of specialty management?

•Prior Authorization with Re-authorization criteria to ensure member is getting best outcomes and is an appropriate candidate in the first place

•Preferred distribution network to gain efficiencies

Maximize plan sponsor satisfaction through

plan design

Maximize planmember

satisfaction

Minimizeplan sponsor

costs

Creating Balance….

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