challenges and innovation in canadian access to treatments and innovation
TRANSCRIPT
Challenges and Innovation in Canadian Access to Treatments and Innovation
November 19, 2015
• George Wyatt • Stephen Frank • Suzanne Lepage • Lisa Callaghan
AGENDA
• Panel A Canadian Public and Private
Access Environment
2
• Panel B Access and Innovation –
International Access to Innovative Therapies
• Neil Palmer • Sandra Anderson • Glenn Monteith
Followed by Qs and As
Followed by Qs and As
Public Drug Plan
Reimbursement
in Canada
November 19, 2015
George Wyatt
Flow of Public Drug Plan
Reimbursement in Canada
© Wyatt Management Consulting Inc., Oakville, Ontario, 2015. All Rights Reserved
Health Canada
Manufacturer
CDR/INESSS (non-cancer) pCODR/INESSS (cancer)
Public Plans
pCPA
PMPRB
CDR vs. Quebec (INESSS)
Recommendations
© Wyatt Management Consulting Inc., Oakville, Ontario, 2015. All Rights Reserved
11
189
141
52
157
89
0
20
40
60
80
100
120
140
160
180
200
Positive Conditional Negative
CDR Quebec (non-cancer)
Conditional recommendations include:
List in a Similar Manner, List with Criteria, List with Criteria/Condition, Not at Submitted Price
pCODR vs. Quebec (INESSS)
Recommendations
© Wyatt Management Consulting Inc., Oakville, Ontario, 2015. All Rights Reserved
Condition for INESSS means conditional of improved cost-effectiveness
Positive for INESSS means conditional (no financial restrictions)
9 8
27
11
*
19
0
5
10
15
20
25
30
Positive Conditional Negative
pCODR Quebec (cancer)
CDR Recommendation Codes
© Wyatt Management Consulting Inc., Oakville, Ontario, 2015. All Rights Reserved
2003 to October 2012
List (LIST) List in a Similar Manner (LSM)
List with Criteria (LWC) Do not List (DNL)
November 2012 To Present
List (LIST) List with Criteria/Conditions (LWCC)
Not at Submitted Price (NSP) Do not List (DNL)
Under Consideration
Fund (LIST) Fund with Conditions (FWC)
Do not Fund (DNL)
www.cdrtracker.com
CDR Patient Input
© Wyatt Management Consulting Inc., Oakville, Ontario, 2015. All Rights Reserved
Voluntary Pipeline Notification/ Mandatory Notification of Submission/Resubmission
CDR notifies Patient Groups for Input
Deliberation/Recommendation
CDR Review Process (Clinical/Economic/Patient Input)
CDR Patient Input
https://www.cadth.ca/about-cadth/what-we-do/products-services/cdr/patient-input
pCODR Patient Input
© Wyatt Management Consulting Inc., Oakville, Ontario, 2015. All Rights Reserved
Mandatory Notification of Submission/Resubmission
pCODR notifies Registered Patient Groups for Input
Initial Recommendation
pCODR Review Process (Clinical/Economic/Patient Input)
Final Recommendation
Patient Groups can only provide feedback on the initial
recommendation if they first provided input in the early
stages of the review.
pCODR Patient Input
© Wyatt Management Consulting Inc., Oakville, Ontario, 2015. All Rights Reserved
https://www.cadth.ca/pcodr/patient-input-and-feedback
Pan-Canadian Pharmaceutical
Alliance (pCPA) – 2015-09-30
© Wyatt Management Consulting Inc., Oakville, Ontario, 2015. All Rights Reserved
80
2
22
11
33
148
54%
1%
15% 7%
22%
100%
0
20
40
60
80
100
120
140
160
Complete Closed(agreement not
reached)
Ongoing Province No Negotiation Total
Number Percent
CADTH Newsletter
https://www.cadth.ca/subscribe
© Wyatt Management Consulting Inc., Oakville, Ontario, 2015. All Rights Reserved
0
50
100
150
200
250
NL NS PEI NB QC ON MB SK AB BC NIHB Avg.
CDR – Public Plan Reimbursement Based on CDR Recommendations from 2004 through 2014
Reimbursed Do Not Reimburse No Decision Yet Removed from Formulary
© Wyatt Management Consulting Inc., Oakville, Ontario, 2015. All Rights Reserved
pCODR – Public Plan Reimbursement Based on pCODR Recommendations from 2012 through 2014
© Wyatt Management Consulting Inc., Oakville, Ontario, 2015. All Rights Reserved
Average Completion Time
© Wyatt Management Consulting Inc., Oakville, Ontario, 2015. All Rights Reserved
203.4 203.1
392
247.1
340.4
0
50
100
150
200
250
300
350
400
450
CDR (Submission toRecommendation)
pCODR (Submission toRecommendation)
pCPA (CDRRecommendation to
Completion)
pCPA (pCODRRecommendation to
Completion)
pCPA (AllRecommendation to
Completion)
Day
s
Time from NOC to
Public Reimbursement
© Wyatt Management Consulting Inc., Oakville, Ontario, 2015. All Rights Reserved
676 628
835
721
800
590
773
1057
404
653 699 712
930
773
1005
1082
981
1094
875
1021 969
738
*
927
0
200
400
600
800
1000
1200
AB BC MB NB NL NS ON PEI QB SK NIHB Average
Day
s
CDR pCODR
* NIHB currently only covers drug that were reviewed prior to pCODR (e.g. jODR)
Summary
• Quebec acts quicker than CDR / pCODR
• Patient input is important for
reimbursement recommendation
• pCPA process is delaying access to
medications
• Overall it takes almost 2 (non-cancer) to 3
(cancer) years from time of NOC to have
drug reimbursement
19
Presentation to Expert Patients Forum Private Payer Industry Trends & Emerging
Considerations
November 19, 2015
Stephen Frank Vice President, Policy Development and Health
19
Prescription Drugs: costs are rising again
• Recent cost growth – while at historical lows – remained higher for private payers than provinces
• Cost's are rising back to more of the historical average
• Specialty drugs driving much of this and pose serious concern
• New challenge: mass market + high costs = budget buster
• Private insurers drug pooling framework is helpful, but growing unexpectedly quickly
20
Employers are the ones who bear these costs – not insurer. They are increasingly looking for ways to limit their financial exposure to new, high cost drugs
Provincial gov't responses: program changes
• Across the board, provinces are responding with changes to their programs, although each on their own priorities and timelines
21
Provincial gov't responses: collaboration to reduce prices
• General view that prices are relatively high in Canada
• Provincial governments working together to negotiate lower prices for brand drugs and generics
– 9 provinces participate in pan-Canadian Pharmaceutial Alliance (PCPA)
• NB: Quebec joined in October; Federal plans will join in 2015/16
– PCPA completed 68 pricing negotiations – estimated $400 million per year in savings
– These rebates are confidential and do not apply to private payers
22
23
Insurers' responses: unprecedented innovation
Managed Formularies
Mandatory Generics
Step Therapy PPNs
Case Management
24
Insurers' responses: Advocating for system reform
Include all payers in PCPA
Continued reform of generic drug pricing
Fundamental reform to PMPRB
• In addition, individual insurers starting to engage in pricing agreements – varying degrees of energy around this at the moment
25
Thoughts on the future
26
Closing thoughts
• New specialty drugs will continue to strain sustainability and drive dialogue around major reform
• Government healthcare reform will continue and accelerate
• Insurers will continue to enhance their capabilities
• Only long-term solution is for greater collaboration between public and private sectors
• Without reform, unclear that the system is sustainable
27
Thank-you
REPRODUCTION REQUIRES PERMISSION OF SUZANNE LEPAGE CONSULTING INC. 28
Evolution of Private Payer Plans in Canada
Expert Patient Advocates and 21st Century Therapies Forum
Hyatt Regency Toronto Toronto, Ontario
November 19, 2015
Presented by: Suzanne Lepage, Private Health Plan Strategist
REPRODUCTION REQUIRES PERMISSION OF SUZANNE LEPAGE CONSULTING INC.
2014 Drug Trend Report • Average annual drug spending per claimant increased by 2.7% (up from
1.3% in 2013)
• Spending on traditional prescription medications declined by 0.3%
• 12.1% increase in spending for specialty medications
o 9.2% increase in cost per script
o Utilization grew 2.9%
o Represents only 2% of claims, but 26.5% of total spending
o Expected to reach 35% in the next four years.
• Top 1% of all claimants comprised 28% of total spending
o Total spending for the top 1% = bottom 85%
29
Express Scripts Canada 2014 Drug Trend Report
REPRODUCTION REQUIRES PERMISSION OF SUZANNE LEPAGE CONSULTING INC.
Hepatitis C Impact on Private Drug Plans
Green Shield (2013 to 2015)
• For all hepatitis C drugs combined
o Claims increased by 189%
o Spend increased by 424%.
Express Scripts Canada (2014 Drug Trend Report)
• Hepatitis C = therapy class with most growth in 2014
• Overall trend increased 252%
o Utilization increased by 132.7%
o Cost increased by 118.5%
• Spending on hepatitis C increased more than 10x in 15 months
http://www.greenshield.ca/sites/corporate/en/Documents/Follow%20the%20Script/2015/Follow%20the%20Script_Fall%202015.pdf
http://www.express-scripts.ca/sites/default/files/ESC_14101_annual_report_ENG3.pdf
REPRODUCTION REQUIRES PERMISSION OF SUZANNE LEPAGE CONSULTING INC. 31
Private Drug Plan Trends
Impact on Specialty Drug Access
1. Case management of drug claims
2. Increased Prior Authorization
3. Preferred Pharmacy Networks (PPN)
4. Managed Formularies
5. Maximum Allowable Cost (MAC) Pricing
6. Step Therapy
7. Government Integration
8. Product Listing Agreements
REPRODUCTION REQUIRES PERMISSION OF SUZANNE LEPAGE CONSULTING INC.
Food for thought…. 1. How are private plans assessing drug value and comparing
treatments? What is the right price?
2. What is the purpose of a benefit plan? Cover every drug plan members need? Or protect from catastrophic illness?
3. Drug plan costs are a line item for plan sponsors to manage. Confidentiality impacts plan sponsors ability to assess the value of drug coverage, health outcomes or potential impact of plan design changes.
4. Where are the patient stories?
5. How to shift dialogue about drug plans from cost to investment?
32
Lisa Callaghan. MBA, MSc
AVP, Group Product
Manulife Financial
33
End of Panel A
34
Expert Patient Advocates & 21st Century Therapies Forum
International Access to Drugs for Rare Diseases W. Neil Palmer
Toronto November 2015
Australia – Challenges in Funding Rare Diseases
Issues
• Australians are generally waiting from 2 to 4 years longer for access to rare disease therapies available in comparable countries like the United Kingdom, Canada, Germany and the Netherlands.
• Some medications remain unavailable 8 years after becoming available overseas.
• No common definition of a rare disease across the Australian health system – Therapeutic Goods Act includes a limit of 2,000 patients for the
registration of orphan drugs - the equivalent of approximately 1 patient in 10,000 persons
Source: The McKell Institute, Funding Rare Diseases in Australia , November 2014
36
Australia - Recommendations
1. The Australian Government should develop a National Strategy for Rare Diseases that provides a holistic approach to rare disease management
2. Australia should be mindful of international practice and developments when designing rare disease policy frameworks.
3. A more flexible analysis of cost-effectiveness should be adopted in the assessment of new therapies that balances other considerations such as equity, the rule of rescue, community values, patient needs and the long-term costs avoided as a result of access to treatment.
4. The unique nature of therapies for rare diseases, including small patient populations and the implications this has for clinical trials, should be recognised in the evidence requirements for funding.
5. The process for assessing new therapies for rare diseases should be efficient, fit-for-purpose, transparent and informed by community and patient values.
Source: The McKell Institute, Funding Rare Diseases in Australia , November 2014
37
Germany
The Federal Joint Committee in Germany (GBA) commissions IQWiG to examine the benefits and harms of medical interventions and recommends level of additional benefit
Orphan Drugs often given “not quantifiable” benefit
Additional Benefit
Price Discount Negotiation
Implications for Pricing European Prices
Considered
Major
Yes Adjusted premium vs. the appropriate therapy in pricing negotiation
Yes Moderate
Marginal
Not Quantifiable Yes Similar to above Yes
None No (negotiation only if there is no reference group or comparator)
Reference price or at max. the price of the appropriate comparative therapy
No
Less Benefit Yes Discount vs. the appropriate comparative therapy
No
Adapted from: : Markus Jahn, Novartis Pharma GmbH, Pharma Pricing & Market Access Outlook, March 2012
38
England - NICE: Highly Specialised Technologies (HST)
• Highly specialised technology (HST) evaluations are recommendations on the use of new and existing highly specialised medicines and treatments within the NHS in England.
• The HST programme only considers drugs for very rare conditions.
• Most are identified by the National Institute for Health Research Horizon Scanning Centre at the University of Birmingham.
• They aim to notify the Department of Health of new / emerging technologies to be referred to NICE:
– New drugs, in development, at 20 months prior to marketing authorisation
– New indications, at 15 months prior to marketing authorisation
https://www.nice.org.uk/about/what-we-do/our-programmes/nice-guidance/nice-highly-specialised-technologies-guidance
39
Overview of NICE HST Process
1. Provisional evaluation topics chosen 2. Consultees and commentators identified 3. Scope prepared 4. Evaluation topics referred 5. Evidence submitted (clinical & cost effectiveness)
– Manufacturer submission – Statement from non-manufacturer consultees
6. Evidence Review Group (ERG) report prepared 7. Evaluation report prepared
– Includes all of the evidence that will be looked at by the Evaluation Committee: • the ERG report and any comments received on it • written submissions • personal statements from patient experts and clinical specialists.
8. Evaluation Committee – An independent advisory committee considers the evaluation report and hears evidence
from nominated clinical experts, patients and carers. Evaluation Committee discussions are held in public
9. Evaluation consultation document (ECD) if produced 10. Final evaluation determination (FED) produced 11. NICE Guidance issued
https://www.nice.org.uk/about/what-we-do/our-programmes/nice-guidance/nice-highly-specialised-technologies-guidance
40
Compliance with a NICE-approved medicine or treatment
• Commissioners (of the 200+ CCGs) have a statutory responsibility
– to make funding available for a drug or treatment recommended by a NICE TA or HST within the timeframe recommended in that guidance.
– Compliance is therefore achieved if a clinician and their patient think a health technology is the right treatment and it is available on the NHS without any local funding or local formulary restrictions.
• For the avoidance of doubt, when NICE recommends a drug as ‘an option’, this is an option for the clinician and patient to consider alongside other potential treatments, not an option for commissioners or providers to not make the treatment available.
https://www.nice.org.uk/about/what-we-do/our-programmes/nice-guidance/nice-technology-appraisal-guidance/achieving-and-demonstrating-compliance
41
HTA / P&R Activities over Product Life Cycle
Market assessment
Pricing environment
NPV calculations
Business planning
Initial pricing scenarios
Market potential based on price scenarios
Early scientific advice with payers / HTA agencies
Pre-clinical Phase I Phase II Phase III Filing / Pre-marketing
Launch / Contracting Post Launch Price Mgmt
Identify comparators
Define outcomes, trial endpoints
HE study design
Identify P&R barriers
Monitor competitors
Quantitative research
Payer research
Analysis of value scenarios
Initial pricing strategy
Finalize global pricing strategy
Define price corridor / fix target and floor prices for each market
Define launch sequence
Develop global value / P&R dossier
Develop market specific dossiers for affiliates
Negotiate prices
Negotiate risk-sharing / price-volume agreements
Launch approval
Monitor launch process
Indication sequencing
Price change approval
Report / assess mandatory price changes
Monitor price trends globally
Assess impact of exchange rates
Assess impact of new indications
• Patient focused engagement typically not part of the early HTA planning process – should start much earlier – patient groups should be pro-active
• Horizon scanning
• Early advice process
Adapted from Simon - Kucher
<===== Patient Engagement =====>
42
Thank you
43
Biography
W. Neil Palmer
President & Principal Consultant PDCI Market Access Inc
[email protected] www.pdci.ca
Neil Palmer President and Principal Consultant of PDCI Market Access Inc. (PDCI) a leading pricing and reimbursement consultancy founded in 1996. He leads a senior team of market access professionals with pricing & reimbursement engagements covering Canada, Europe, and the United States. Prior to PDCI, Neil worked with the Canadian Patented Medicine Prices Review Board (PMPRB) where his responsibilities included policy development, overseeing the price review of patented medicines and conducting economic research. Prior to the PMPRB, he worked with the Health Division of Statistics Canada where he was responsible for economic and statistical analysis of health care costs and utilization. Neil also worked with RTI Health Solutions (Research Triangle Park, North Carolina) where he served as global vice president for pricing and reimbursement. After completing his studies at the University of Western Ontario, Neil began his career in Montreal with the research group of the Kellogg Centre for Advanced Studies in Primary Care. He has written extensively on pharmaceutical pricing and reimbursement issues and is a frequent speaker at conferences in North America and Europe. In January 2015, Neil was appointed Adjunct Assistant Professor at the University of Southern California School of Pharmacy graduate program in Health Care Decision Analysis where he lectures on health technology assessment, pricing and market access from a global perspective.
44
Customized Patient Care through Patient Support Programs for Rare/Orphan Drugs
Sandra Anderson
November 2015
Why Orphan Drugs are Different
Difficult to diagnose
Population size
Unique patient and caregiver needs
Cost
Reimbursement challenges
Wait times for Specialist
Large amount of stakeholders involved
to get patient on therapy
There is no clear path to get Orphan Drugs Funded
46
A Typical Journey of a Patient with a Common Disease
Insert visual of patient with high
blood pressure- ie asymptomatic
disease
Insert visual of a patient with asthma-
a symptomatic disease
Physician Office
The Patient Journey in Rare Disease
PSP Introduction
• Coverage information is captured
• Services explained
Enrolment in PSP
Demographics, clinical history
Prescription
Journey to Dx
$
Patient set up to
receive treatment Coverage is secured
SA submissions
Life time
Max
Injection/Infusion
Services? Copay?
Call – review
Coverage
decision
Infusion/Injection
Continued Care Calls
• Determine status
• Coach patient
Annual Renewals
Maintenance
Onboarding
Explore
Reimbursement
coverage
Rx
Key Trends for Orphan Drugs
Different reimbursement routes across Canada. Public reimbursement/Private
reimbursement – 50/50
Traditionally very high cost medication requires additional administrative work and numerous
stakeholders involved in treatment
Changes in Private Payer Marketplace ie PPNs
Small patient populations may have regional bias
The Patient Perspective
The high drug cost, and out-of-pocket component, (co-
payment or deductible) can be unmanageable for many
patients (especially for Orphan drugs ~hundreds of 000s/year)
Most income-based public plans such as Trillium in Ontario require patient contributions in
the form of co-payments/deductibles (~3-5%
of household income)
With complex therapies, the primary concerns for patients are access, convenience and the level of customer service
Private plans vary: range from 100% coverage to 50%
coverage, though the most commonly seen co-payments are set between 0 and 20%
Case Study: Real Life Patient Access Barriers Defined
Source: Berry SA, et al. Genet Med 2013:15(8):591–599
Condition and Therapy
Patient
Social and Economic
Healthcare System
Patient Support Programs Focus on Orphan/Rare Disease Drugs
Needs for Orphan Rare Disease PSPs
High Touch Require specific administration or monitoring requirements
before and ordering administration
High Support Education, counselling, compliance monitoring, and drug
information, Customized clinic needs
Special Distribution Special handling techniques; and / or require special handling, have special shipping requirements or need
complex reconstitution
Customized Patient Assistance Clinical , Diet and Lobbying/Financial Support to assist with
access to drug (i.e. co-pay assistance)
Customized Patient Support Programs Nurse Case Manager – One point of contact to deliver quality care at every touch-point
Pre Infusion
Checklist
(Program)
Enrolment
Reimbursement
Specialty
Pharmacy
Update on
Patient
Progress
Infusion Scheduled Patient Experience
*****
Infusion
Drug
Dispensed,
shipped to
clinic)
Nurse
completes
pre-infusion
checklist
Infusion Scheduled: Clinic chosen, Fax to physician, Pre-infusion checklist, Reminder call, Drug order
Enrolment: Entered in CRM, NCM
assigned, patient contacted
Reimbursement: Case Manager confirms coverage with the patient and sets up financial assistance
Specialty Pharmacy: Deferral of copay, Drug Order (Direct through Database), Warehouse sends drug to pharmacy, Drug delivered to Clinic
Infusion: Nurse confirms Drug is onsite, Pre-infusion assessment by nurse, Medical clarification needed?, Infusion, PIR
Patient experience touch-point
Innomar
Nurse Case Manager
Case Study: Coordination of Public Insurance
• Solution
– Public EAP requested
– Patient Advocacy: Lobby on behalf of
patient; media releases; Canada wide
petition; add pressure to decision makers;
weekly telephone conferences with
stakeholders
• Outcome
– Provincial compassionate program obtained
to start and then successfully gained full
approval from the province
Patient is still on therapy!
Challenge: Patient was hospitalized
with multiple organ failure.
The medication was still
under review by the
Province.
Case Study: Reimbursement Solutions in Rare Diseases
CLIENT SITUATION
Client was having challenges
obtaining coverage for their
orphan drug with a major
private payer.
OUR SOLUTION
Payer wanted real health outcomes data and a
negotiated a price per patient based on HO data.
Innomar worked with the manufacturer to obtain and
analyze relevant HO data from their patient support
program.
Innomar developed PLA scenarios and brokered the
meeting between manufacturer and payer to negotiate a
listing.
OUTCOME
Manufacturer was successful in obtaining their desired PLA
scenario
Program continues to report monthly HO data, and payer
continues to cover patients who meet agreed upon criteria.
KEY INSIGHT
Building a data strategy early-on and
utilizing relevant data through the PSP
will be critical to the overall market
access strategy
Conclusions and Key Insights to Consider
• Diagnosis
• Testing
• Reimbursement
• Financial assistance
• Ongoing treatment
• Monitoring
Rare diseases present unique
challenges for:
• Product focused, patient centric;
• Gather valuable real life data extremely useful for payers – useful for potential Adaptive Listing initiatives;
• Manufacturer funded with the opportunity to become more centralized to support overall Rare Disease Strategy
PSPs for Rare Diseases are:
Key Goal: Leverage your PSP to demonstrate
real world effectiveness value to gain access to payers
58
Rare diseases present unique challenges for:
- Diagnosis, Testing,
- Reimbursement, Financial assistance,
- Ongoing treatment
- Monitoring
PSPs for Rare Diseases are:
- Product focused, patient centric;
- Gather valuable real life data extremely useful for payers – useful for potential Adaptive Listing initiatives;
- Manufacturer funded
- Opportunity to become more centralized to support overall Rare Disease Strategy
Ultimate objective is to build a build a different framework for Orphan Drugs which will shorten the timelines to access
Health
Outcomes
Research
Value to
Payers
Patient
Support
Program
Demonstr
ate
Real
World
Effective
ness
and
Value
Presentation to Expert Patients Forum
Innovative Pathways to Drug Access in Private Drug
Coverage Plans
November 19, 2015
Glenn Monteith
Vice President Innovation and Health Sustainability
November 19, 015
60
Players involved in private market – insurers and
others
Plan Members
19 Million
Plan Sponsors
500,000+
Advisors & Consultants
3,000
Insurance Carriers
24
Pharmacy Benefit
Managers
3
Community Pharmacies
8,600
• Many players and decision-makers are involved in private
drug plans
Diseases Have Major Impacts on Canadian Economy
Diseases affect productivity at work, both physically and/or mentally
Examples:
62
1 Source: http://www.phac-aspc.gc.ca/media/nr-rp/2011/2011_0919-bg-di-eng.php 2 Source: Cranswick K., Dosman D. Eldercare: Canadian Social Trends. 2008, Vol. 86, pp. 48-56 and Fast, et al. A Profile of Canadian Chronic
Care Providers: A Report Submitted to Human Resources and Development Canada. Univ. of Alberta. Edmonton : s.n., 2002.
$7,000 / employee / year
Presenteeism
$10,000 / employee / year
Abstenteeism
Chronic Diseases Have a Big Impact on Productivity
and Absenteeism
Top 15 drivers of lost work time Total cost of condition of employees
with a primary condition
63
Source: Kessler’s HPQ—Adjusted to work Force (2007) Source: Collins et al, Assessment of chronic conditions
on work performance, absence and total economic
impact for employers, NEOJM, 2005
Cost containment measures
used by private drug plans
64
Generic substitution
• Not mandatory – physician may prescribe innovative medicine and
write “no substitution”
• Mandatory – in all cases, a generic drug, if available and considered
“interchangeable” then it will be dispensed, or, plan only pays up to
cost of generic drug and plan member must pay the difference in
price to access the innovative medicine *exceptions process for
some plans
Get to know your plan options and ask questions of your
pharmacist/pharmacy when getting a prescription filled.
65
Prior Authorization GWL 100+ Drugs
Tiered Formulary
Therapeutic Sub / Mac Price
Case Management
Summary of Scorecard Findings – 2013 Actuals
• PDP drug cost growth in 2013 is the lowest in recent years.
• Drug cost growth of 2.2% was in line with the Forecast CAGR (1.6% to 2.8%) for the 2013-2017 forecast period.
• Generic savings was higher than forecast; as anticipated generic pricing changes had the greatest impact.
• Impact from new medicine entry was lower due to a mix consisting of fewer specialty medicines than forecast.
• Though marginal, the aging event had a slightly higher impact than forecast due to growth in the number of older claimants and increase in utilization amongst these older claimants.
70
Closing thoughts
• Private drug plans are important to providing access to innovative
medicines and vaccines
• Get to know your plan and inform yourself of how plan design
features can impact access
• Coordination of benefits between plans (e.g. public and private or
two private plans) can be complex
Rx&D advocates for timely, quality access to innovative medicines and
vaccines so people get the treatments they need when they need them.
71
End of Panel B
72