Pharmacy Benefits and ProgramsA true area of excellence for

Blue Cross and Blue Shield of Florida

2

Pharmacy Management Strategy

• Goals• Meet employer/customer expectations regarding

understanding of prescription drug utilization, market and cost trends and pharmacy benefits

• Optimize the quality of pharmaceutical care• Develop programs to positively impact Rx utilization and total medical cost• Promote understanding of medication effects, safety, appropriate use and

the value of adherence to treatment regimens• Cover medications that offer optimization of health outcomes and

represent the best overall value for members

Ensure customer access to safe and clinically effective medication that improves

health care outcomes while maintaining affordability.

3

Utilization Management Programs

• Utilization management programs use clinical criteria and best practices to control member over and under utilization

• Through combining medical and pharmacy claim data, this program delivers more accurate targeting, higher provider and member satisfaction, and better quality of care outcomes

4

Responsible Steps

• Program details– Promote safe and effective use of medications– Reduce inappropriate use of medications– Increase member savings– BCBSF’s clinical step-therapy program

• Requires trial of one or more alternative medications before coverage of a targeted drug

• Only certain medications included; selection based upon sound clinical quality and safety data that justify inclusion in program

• Targeted Drug Class: Cox-II Inhibitors (Celebrex), Byetta, Insomnia Agents, Atopic Dermatitis, Statins

•

5

Responsible Dose – Medication Dosing and Compliance Initiative• FACTS

– Many prescriptions are written for two doses of a lower strength to be taken daily

– These medications are available in one tablet dose prescription

– One tablet dosage = less cost for BCBSF and more convenience for the member

• GOAL– Change prescriptions written for multiple daily doses to

single daily dose • ACTION

– Targeted mailings to ask physician to consider a change to once-a-day doses or requests member to talk to their physicians

• OUTCOMES– Enhanced member convenience and improved adherence– Reduced potential benefit abuse (>31 tablets for one copay)– Reduced Rx costs

RESULTS

45% of physicians approve dosage changes

$34 average net savings per Rx changed

6

Responsible Quantity – Coverage Maximum Initiative • Quality initiative with a focus on a maximum

recommended dose of specific medications based on dosing guidelines established by the manufacturer and FDA

• Includes a monthly coverage maximum based on the recommended dosage and duration of therapy

• Valuable information provided to the prescribers and member-patient to make appropriate medical condition therapy choices

• Results of the initiative were nationally recognized in a peer-reviewed pharmacy publication

EXAMPLE SAVINGS

(with one drug category – migraine

medications)

$8.44 PMPM enrolled migraine

member

7

Copay Waiver Program

Value: For every 1% increase in generic dispensing rate there is an approximate 1% decrease in drug spend

• Patients taking any of the brand medications listed in the program may speak with their physician, and if ok can switch to the generic or over the counter medication. BCBSF will then initiate a one time waiver of the first copay(retail or mail order).

8

BCBSF Generic Initiatives• Benefit Design

– Generics Lowest Member Cost Share

– Formulary Design

• Clinical Programs– Copay Waiver

• Member and Provider Communications– Florida Blue Publication

www.bcbsfl.com– BlueLine

www.bcbsfl.com– Member Mailings

• Medication Therapy Management Programs– Step Therapy– Prior Authorizations– Responsible RX

• Web Tools– Cost comparisons– Preferred Medication List

9

Specialty Pharmacy Management• Program Goals

– Simplify the physicians/members acquisition of injectable drugs for improved member access

– Streamline the process for submission of claims for injectable drugs to enable trend management

– Promote safety through utilization management initiatives– Provide a cost-effective, quality service for members

BlueOptions and BlueChoice

Injectable Medication Program Suppliers

CVS/Caremark

Physician-administered medications covered by

Medical benefit

Self-administered medications covered by

Medical benefitPharmacy benefit (on-line claim processing)

Prior Authorization Requirement

(800) 955-5692

Medical benefit: NoPharmacy benefit: Yes

10

BCBSF Injectable Program

• Provider and Member Access– Specialty Rx-Fully Array of Solutions

• CVS/Caremark• Dedicated Hemophilia Provider: Accredo • Plus Retail Pharmacy Network

• Provider Office & Home Delivery through Injectable Drug Supplier (IDS) and BlueOptions Drug Supplier (BOIDS) network

• Drug Replacement available to providers

11

Cost Containment: Pharmacy Programs

Incentive Based Formulary Managed by Pharmacy & Therapeutics Committee and is comprised of practicing physicians and pharmacists.

Dose Optimization ProgramBCBSF Drug Dosing Initiative exists in order to provide you information that may help improve compliance to long-term medicines.

RESPONSIBLE RXResponsible Quantity

(coverage maximum program)

• A limited list of medications have a maximum quantity for which coverage will be allowed for one month.

• The maximum quantity covered is based on FDA and the manufacturer’s dosing recommendations

Copay Waiver Program

Members who have been taking certain brand-name medications and switch to a generic or over the counter medication can have their first prescription copay waived! That is, the member can try a generic for FREE! (ASO group approval required)

12

Cost Containment: Pharmacy Programs

Prior AuthorizationBCBSF has Prior Authorization processes in place for certain specified self-administered injectables when a physician or member desires to obtain those medications via the member’s pharmacy benefit rather than under their health coverage benefit.

Appropriate Antibiotic Prescribing

• Appropriate antibiotic prescribing is promoted through provider educational initiatives and member mailings.

Medication Withdrawal – Recall Notification

Program

• When medicine safety data becomes available, we strive to provide physicians information that may be helpful. We watch for “news” items, pharmacy literature and medical literature about all medication safety issues to assist our members and their prescribers.

• In addition, in each publication of our member newsletter we include a column dedicated to medication safety and provide tips to our members about how to "stay safe" with medication therapies.

RESPONSIBLE RXStep Therapy

• The application of on-line step therapy edits is used to ensure appropriate use of preferred first line medication treatment options prior to second line drug medication and the promotion of generic medication options being utilized.

• The step therapy program will be implemented as an electronic prior authorization process that occurs at the time a pharmacy submits a prescription claim electronically.

Poly-PharmacyA new voluntary Commercial Poly-pharmacy Program, which encourages members with multiple chronic medications to review their medications and supplements with their doctor began in October 2007. The program targets members in commercial plans who are taking five or more chronic medications for three consecutive months, prescribed by more than one physician. Members matching the criteria, identified by claims data, are at higher risk for adverse effects, drug interactions and non-compliance.

Tablet Splitting

A new voluntary program for targeted members of our group commercial products with a co-insurance benefit design taking a select list of medications. This program allows them to take their dose of medication in a half-tablet rather than a whole tablet. Participating members will save half of their coinsurance. The start date of this program was Jan. 1, 2008.

13

Cost Containment: Prior Authorization for Self-Administered Injectable Drugs

• Actimmune Geref PA Norditropin PA • Aranesp PA Glucagon Emergency Kit Nutropin PA • Arixtra PA Humatrope PA Nutropin AQ PA • Avonex Humira PA Omnitrope PA • Betaseron Imitrex Pegasys PA • Calcijex (calcitriol) 1 mcg/mL Increlex PA Peg-Intron PA • Calcijex 2 mcg/mL Innohep Procrit PA • Copaxone Intron A PA Prostigmin • DDAVP (desmopressin) 4 mcg/mL Iplex PA Raptiva PA • D.H.E. 45 (dihydroergotamine) Kineret PA Rebif • Eligard PA Leukine PA Roferon-A PA • Enbrel PA Lovenox PA Saizen PA • EpiPen Lupron (leuprolide) PA Sandostatin (octreotide) • EpiPen Jr Lupron Depot PA Serostim PA • Epogen PA methotrexate Somavert • Forteo PA Miacalcin Tev-Tropin PA • Fragmin PA Neulasta PA Vidaza PA • Fuzeon Neumega PA Zorbtive PA • Genotropin PA Neupogen PA

• Note: For our BlueSelect product, the following drugs also require authorization: Zyvox, Actiq, Fentora and oral Fentanlyl.

The following self-administered injectables require authorization when a physician or member desires to obtain those medications via the member’s pharmacy benefit rather than through health benefits.

As of October 2008

14

• Access through MyBlueServiceSM Capabilities– Provides up to one year Pharmacy Claims &

Expense History – Pharmacy Locator with Map Quest– Formulary Search – Provides Alphabetical and Therapeutic

Medication Guide Listings– Supplies Medication Costs– Offers information on savings through use of

generic medications– Provides access to:

• Drug Information – drug-drug interactions– drug-food interactions– Side effects & precautions

• Mail order – Refills – Order status

MyRxHealth MyRxHealth

* Provided through Prime Therapeutics LLC®

Member’s Personal, Online Pharmacy Portal

15

We’re Committed to Listening and Providing Caring Solutions

• Our mission as a strategic partner of the colleges is to customize your plan designs for ultimate flexibility and plan options that meets the individual needs of each college.

• Our strategies include pricing to reflect your colleges’ experience while taking advantage of pooling though the Consortium.

• A focused approach and support in facilitating your wellness program.

• THANK YOU for the trust and confidence you place in us in meeting the needs of your college.

16

Thanks for the opportunity to serve you!