Specialty Drug Benefit Management:

Raymond Rupert MD. MBA.

Rupert Case Management Inc.

Specialty Drugs Are Smart:

• Rituximab (Rituxin) by Roche can improve survivorship in lymphoma by 50%

• Smart drugs create fewer side effects

Specialty Drugs Are Costly:

• Average cost $65,000 per person per year

• Doctors using two or three biologicals at one time

• Problem: managing the rapidly escalating costs of specialty drugs

The Future Looks Expensive:

• 641 class D drugs licensed in Canada

• + 800 specialty drugs in the pipeline

• 35,000 patents in 2009 for specialty drugs

RCM’s Integrated Service:

• RCM manages the total specialty drug benefit from start to resolution

• for TPAs,

• benefits consultants

• insurers

• drug plans or employers

RCM’s “Lean On Me” Service:

• This service provides the client with a:– Mentor– Advisor– Medications Expert– Purchasing agent– Logistics manager – Confidante and– Friend

OUR NEIGHBOURHOOD:

Customer Rx

Clinical Planreview

RCM

Treatmentreview

Treating doctors Clinical researchers

Case conference

Top DOCS

Determine Txoptions

Evidence based report

Alternatives

Genetic marker testing

siRNA

Clinical trials

Prior authorization

Finalize Rx

Purchase

DistributorsSuppliers

Infusion centers

Cold chain

Competitive sourcing

Coordination of benefits

Coordination of care

Monitoring/Aftercare

Employer funding

PAP

Private funding

Public funding

Other sources

Gord’s Case Study:

• Gord is a 60 year old business person• Leukemia + Non-hodgkins lymphoma• Rituxin from Roche was advised• Not eligible for the provincial plan • Coverage with his private drug plan• Infusion issue in hospital• Outcome: 50% improvement

in survival

RCM’s Enhanced Customer Experience:

• Clarity in communications

• Decision support that is impactful

• Guidance that is relevant

• Effective advocacy

• Emotional support

• Engagement of patient + family

RCM Provides Decision Support

• Audit the clinical situation

• Review the treatment plan

• Source second opinions if required

• Invites outside experts to a virtual case conference

• Keeps patient fully informed

Pharmacogenomic Testing:

• RCM arranges tests for genetic variation

• Determine if drug will work and ensure that side effects will be minimized

• HER2 test with Trastuzumab (Herceptin)

• K-RAS test with Cituximab (Erbitux)

• EGFR test with Gefitinib (Iressa)

Option of Clinical Trials:

• RCM tracks clinical trials

• Understands the entry criteria

• Assesses the design • Blinded• Unblinded• Placebo group

• Completes the paper work

• Ready with Plan B, C, D if rejected

RCM’s Job One: Ensure Appropriate Utilization:

• RCM ensures that:• The right person • Gets the right medication• For the right indication• At the right dose • At the right time• Through right route• At the right price • For right length of time

Many Possible Funding Sources:

• RCM can seek public or private funding

• RCM uses patient assistance programs

• Access pharma company sponsorship

• Access employer funding on an exception basis

Co-ordination of Benefits:

• Careful juggling of benefits practiced here!

RCM Monitors Compliance + Adherence:

• RCM monitors if the drug is being used properly to achieve the best possible outcome for the cost incurred

RCM Delivers Lowest Cost Sourcing:

• RCM seeks the lowest cost product using competitive sourcing

• RCM understands “off label” indications

• Different products with same benefit sold at markedly different price points

Realize Cost Savings:

• Treatment of macular degeneration

• Use Lucentis $2000 per treatment

• Or use Avastin at $100 per treatment

• Savings for the drug plan of $1900 per treatment with RCM’s benefit management

RCM’s Client Monitoring:

RCM provides monitoring and aftercare for as long as is needed

Benefits Of Retaining RCM:

• 1. Lower costs for the employer + the plan• Improve the sustainability of the plan• Delivery of performance metrics

• 2. Seamless transitions

• 3. Continuity of care

• 4. Enhanced customer experience

• 5. Hopefully better outcomes

• 6. Enhanced employee loyalty

To Learn More About RCM’s Specialty Drug Benefit Management:

• Call- 800 620 7551