Well Informed. A Comprehensive Approach to Pain Management. Pain Guardian

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1 Q Well Informed A Comprehensive Approach to Pain Management Use of opioids is common and necessary to support treatment for a wide variety of health related issues; however, the use of opioid medications poses risks to patients and plan sponsors alike. According to the CDC, since 2000, the death rate from drug overdoses involving opioids increased 200% (including opioid pain relievers and heroin). With the growing number of adverse events associated with the use of chronic opioids, plan sponsors need to find a way to maintain access to these medications while prioritizing patient safety and controlling costs. Since 2000, the death rate from drug overdoses involving opiods increased 200%. - CDC Pain Guardian WellDyneRx offers a comprehensive pain management strategy that supports evidence-based care and cost-effective prescribing using the following combination of methods: The WellDyneRx Pain Guardian program enables our clients to implement clinical strategies that promote safe and effective use of opioids. Recent client successes with this program include: Reducing unneeded opiate use by 12% Decreasing the amount of chronic opioid users by 36% Downgrading the number of patients that exceeded patient risk scores thresholds by 19% ering associated pain management per utilizer costs by 19% The WellDyneRx Pain Guardian programs leverage Morphine Equivalent Dose (MED) checks at the point-of-sale (prior to pharmacy dispensing) to ensure high dosage patients are being carefully monitored by their physician(s) and receiving appropriate prescriptions. (Continues on next page)

2 2017 Drug Pipeline REPORTS NOW AVAILABLE Please click the links below to access WellDyneRx s bi-annual drug pipeline reports: Biosimilar Drug Pipeline Report Brand Drug Pipeline Report Generic Drug Pipeline Report Specialty Drug Pipeline Report These publications include: Descriptions of drugs/products in development, including product highlights, place in therapy, and market impact Summaries of specialty, non-specialty, biosimilar, and generic drugs with anticipated FDA approval dates in the upcoming 12 months or in late-phase clinical trials Additional FDA actions, including rejections and indications for specific drugs If you have any questions, please contact your Account Executive. A Comprehensive Approach to Pain Management continued Compound Management Compounded treatment of pain management represents a unique opportunity to minimize the amount of opioids for patients with chronic pain. However, the safety and efficacy of some of these compounded products isn t currently available and, as such, WellDyneRx requires a medical necessity review with the prescriber prior to adjudication. We also block bulk ingredients, such as lidocaine, that drive significant plan spend. Additionally, we recommend implementing prior authorizations (PAs) for compound pain management medications that include lidocaine, baclofen, diclofenac, Seroquel (quetiapine) and ketamine to ensure patient safety; prevent fraud, waste, and abuse; and control costs. Exclusions of High Cost Topical Pain Products Pain patches and creams (excluding opioid pain patches) do not go through the same rigorous FDA approval process as most medications. These products receive FDA approval because they contain at least two FDA-approved drugs, but the final, combined medication has not been adequately tested for safety or efficacy. Manufacturers are able to charge exceptionally high ingredient costs to produce these patches and creams even though comparable OTC products are often available at a much lower price. WellDyneRx recommends excluding these topical pain products from coverage due to their high cost, limited value, and the availability of less expensive, comparable OTC alternatives. Prior Authorizations (PAs) and Quantity Level Limits (QLLs) WellDyneRx continually reviews our PA lists to ensure prescribing practices for pain medications are consistent with current evidence and guidelines. We also offer QLLs based on safety and efficacy testing for pain management. Quantities above the recommended limits are allowed on a case by case basis when evidence supports the use of higher doses. To learn more about our comprehensive Pain Management programs, contact your WellDyneRx Account Executive.

3 US Specialty Care Specialty Pharmacy Services As specialty drug costs continue to drive plan spend, US Specialty Care (USSC), WellDyneRx s wholly-owned specialty pharmacy, uses unique strategies and formulary options to help contain the cost of specialty products. USSC is widely recognized as a best-of-breed specialty pharmacy and continually yields industry-leading results for our clients: Industry-leading Specialty Adherence Rates Improving medication adherence rates can lead to a reduction in overall healthcare costs by reducing hospital readmissions and improving plan participants general health. Adherence is measured by two main industry standards: Medication Possession Ratio (MPR), which measures the percentage of time a patient has medication on hand, and Proportion of Days Covered (PDC), which measures the period covered by prescription claims for the same medication or another in its therapeutic category. Industry benchmarks indicate that 80% of patients should take at least 80% of their medication in order to be considered adherent. The average MPR of US Specialty Care patients is 92.76% and the average PDC is 90%. The average MPR of US Specialty Care patients is 92.76% and the average PDC is 90%. Drug Manufacturer Coupon Savings The Intercept TM program is a patented clinical offering designed to manage, identify, and reduce the cost of frequently prescribed specialty medications that offer a direct-to-consumer assistance program from the manufacturer. The average savings with Intercept is over $500 per medication fill. These savings are in addition to AWP discounted costs. Hepatitis C Cost Containment WellDyneRx was the first PBM in the country to adopt a lowest net cost hepatitis C (HCV) formulary, using Zepatier as our preferred product. Health outcomes for patients using Zepatier are equivalent - or better - than higher cost medications in the same class. Zepatier patients take fewer pills, making adherence to the drug regimen easier. USSC pharmacists converted 84% of the requests they received for HCV medications to the preferred product, Zepatier. Switching to Zepatier resulted in savings of over $31,000 in ingredient costs per converted patient. Switching to Zepatier resulted in savings of over $31,000 in ingredient costs per converted patient. Limited Distribution Drugs Certain medications can only be dispensed from a very limited of number of pharmacies due to the need to manage the risks associated with such products. These medications are called limited distribution products, or LDDs. On November 1, 2016, USSC began dispensing two LDDs, Aubagio and Cosentyx, which cumulatively account for 10% of our clients limited distribution drug costs. This development demonstrates the value of USSC in managing specialty conditions. Aubagio is prescribed to treat multiple sclerosis (MS) and Cosentyx is used to treat plaque psoriasis and certain types of arthritis. We are very proud to be selected as a LDD partner for these medications and look forward to expanding access to other medications soon. For additional information regarding USSC, please contact your Account Executive.

4 2017 Clinical Program Updates As part of our commitment to evidence-based care and cost-effective prescribing, WellDyneRx regularly reviews and enhances our clinical programs to ensure our solutions are comprehensive and bring the most value to our clients. We ve made the following updates to our 2017 clinical offerings: Compound Management Compounding continues to be a significant cost trend driver despite claim limits established by employers. The WellDyneRx compound management program requires medical necessity reviews with prescribers before adjudication. This year, we are excluding more bulk ingredients and compounding kits to control costs and ensure appropriate prescribing. Early Alert WellDyneRx Early Alert clients receive a monthly report that captures new utilizers of chronic medications for major disease states including high cholesterol, diabetes, asthma, and high cholesterol. We recently enhanced our reporting capabilities to include more disease states and adherence information. Intercept Through the Intercept program, WellDyneRx clients are able to maximize manufacturer copay assistance without negatively impacting plan participants. Our list of specialty medications eligible under this program expanded in 2017 to include 63 products. We will continue to add medications to this list whenever possible. Medical Specialty Cost saving measures are not unique to the pharmacy benefit. Medical Specialty is a program offering site-of-service management for medications adjudicated under the medical benefit. Pain Guardian The WellDyneRx Pain Guardian program enables our clients to implement clinical strategies that promote safe and effective use of opioids. We now offer two different program package levels to fit our clients diverse needs. Risk Stratification Tool for Pain Management Patients The WellDyneRx clinical team developed new ways to identify members being treated for pain that are considered high risk for hospitalizations and/or improper prescribing. We notify our clients as quickly as possible when these high-risk plan participants are detected so that additional support and outreach can be provided as needed. Six Month Exclusion This program blocks new medications to market for a period of six months until they can be reviewed by our P&T committee. This allows for a full clinical review by an independent team of physicians prior to placement on our formularies and implementation of prior authorization criteria. For more information regarding any of our clinical programs, please contact your Account Executive.

5 NEW FDA-APPROVED DRUGS BRAND NAME GENERIC NAME(S) THERAPEUTIC USE BRIEF DESCRIPTION POTENTIAL IMPACT Tecentriq (Genentech) atezolizumab Bladder cancer Tecentriq is indicated for the treatment of patients with locally advanced or metastatic urothelial carcinoma (muc) who have disease progression during or following platinum-based chemotherapy, or whose disease has worsened within 12 months of receiving platinum-based chemotherapy before or after surgery. The recommended dose of Tecentriq is 1200mg as an intravenous (IV) infusion over 60 minutes every 3 weeks. Lartruvo (Eli Lilly) olaratumab Soft tissue sarcoma Lartruvo is the first monoclonal antibody to be indicated for treating adults with soft tissue sarcomas (STS). Recommended dosing for Lartruvo is on 21-day cycles with 15 mg/kg given as a 60-minute IV infusion on day 1 and day 8. Doxorubicin is given along with Lartruvo for the first eight cycles. Treatment continues until the patient can no longer tolerate side effects or until the cancer ceases to respond. In the open-label, Phase II JGDG clinical trial, median overall survival was nearly one year longer among patients using Lartruvo and doxorubicin than among patients on doxorubicin alone. Zinplava (Merck) bezlotoxumab Clostridium difficile (C. diff) Zinplava is a monoclonal antibody used as ancillary treatment to decrease the likelihood of a relapse with a specific bacterial infection. It is approved by the FDA for use in combination with an antibacterial for preventing recurrence of Clostridium difficile (C. diff) infection for patients who are at least 18 years old, who are undergoing antibacterial treatment for C. diff and who are at high risk of acquiring the infection again. Recommended dosing is 10mg/kg given as a single IV infusion over a one-hour period. It must be used in conjunction with an antibacterial agent.

6 NEW FDA-APPROVED DRUGS BRAND NAME GENERIC NAME(S) THERAPEUTIC USE BRIEF DESCRIPTION POTENTIAL IMPACT Bonjesta TM (Duchesnay) doxylamine/ pyridoxine Nausea and vomiting associated with pregnancy Bonjesta extended-release tablets combine 20mg each of an antihistamine (doxylamine) and a form of vitamin B6 (pyridoxine). It is indicated to treat nausea and vomiting associated with pregnancy when conservative treatment, such as dietary modification, is not effective. If the recommended dose of one tablet at bedtime does not control symptoms, an additional tablet may be added in the morning. No more than two tablets should be taken per day. Moderate Vemlidy (Gilead) tenofovir alafenamide Chronic hepatitis B Vemlidy is indicated to treat patients who have chronic hepatitis B that has not yet progressed to cirrhosis. Because Vemlidy maintains relatively constant blood levels, it is effective at a lower dose (25mg/day) than Viread (tenofovir disoproxil). Consequently, Vemlidy does not cause as many side effects, particularly on bones and in kidneys. Recommended dosing is one tablet daily along with a meal or snack. Intrarosa (EndoCeutics) prasterone Vulvovaginal atrophy Intrarosa vaginal inserts treat vulvovaginal atrophy (VVA). This is a condition that makes having sex painful and difficult for many women after menopause due to alkalinity, dryness, irritation and thinning of the female lower reproductive tract. Also, widely known as DHEA, prasterone is a natural steroid hormone produced mainly by the adrenal glands and then converted into estrogens and androgens. Biological prasterone production gradually decreases around age 30. At menopause, estrogen drops even further. Intrarose is the first prescription prasterone to be FDA-approved. It will be available as 6.5mg vaginal inserts that are used once daily. Moderate

7 NEW FDA-APPROVED DRUGS BRAND NAME GENERIC NAME(S) THERAPEUTIC USE BRIEF DESCRIPTION POTENTIAL IMPACT Xultophy (Novo Nordisk) insulin degludec / liraglutide Diabetes Xultophy combines the company s Tresiba (insulin degludec) and Victoza (liraglutide) into a once-daily subcutaneous injection. Xultophy is indicated for the treatment of adults with type 2 diabetes that are inadequately controlled on basal (long-acting) insulin or GLP-1 agonists as monotherapy. High Soliqua (Sanofi) Insulin glargine / lixisenatide Diabetes Soliqua is a fixed-dose combination product of 100 units per ml of Lantus (insulin glargine) and 33 mcg per ml of Adlyxin (lixisenatide) and comes in a 3 ml single-patient use pen. It is indicated as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes. Soliqua is dosed once-daily by subcutaneous injection and the recommended starting dose is 15 units. High Synjardy XR (Eli Lilly / Boehringer Ingelheim) Empagliflozin / metformin extended-release Diabetes Synjardy XR is a long-acting, once daily medication that improves glycemic control for adults with type 2 diabetes mellitus. Empagliflozin is a sodium-glucose co-transporter 2 (SGLT2) inhibitor, a drug class that blocks reabsorption of glucose in the kidneys. Metformin lowers glucose production and raises insulin utilization. High Eucrisa (Pfizer) crisaborole Eczema Eucrisa 2% ointment is the first topical phosphodiesterase 4 (PDE-4) inhibitor indicated to treat eczema in patients two years of age and older. Atopic dermatitis is a common form of eczema. Eucrisa is applied to the affected area of skin twice a day. Moderate

8 NEW FDA-APPROVED DRUGS BRAND NAME GENERIC NAME(S) THERAPEUTIC USE BRIEF DESCRIPTION POTENTIAL IMPACT Rubraca (Clovis Oncology, Inc.) rucaparib Ovarian cancer Rubraca is indicated for ovarian cancer that has progressed despite at least two chemotherapy treatments and that has a deleterious BRCA genetic mutation. Rubraca is an oral drug with recommended max dosing of 600mg twice a day until the cancer worsens or the patient cannot take the drug any longer. Two different strengths of Rubraca were approved: 200 mg and 300 mg. Spinraza (Biogen / Ionis) nusinersen Spinal muscular atrophy (SMA) Spinraza is the first drug indicated to treat spinal muscular atrophy (SMA), a rare genetic condition that causes increasing weakness in muscles. Spinraza will be given directly into the fluid around the spinal cord by a healthcare provider who is trained to perform spinal procedures. Recommended dosing is three 12mg doses administered at two-week intervals, followed by a fourth dose one month after the third; and then by one dose every four months.