WellDyneRx 34% 1 2% Inflammatory Con Diabetes MS Oncology Asthma/COPD High Blood Pressu HIV Pain/inflammation High Blood Choles Attention Disorde Inflammatory Con Diabetes MS Oncology Asthma/COPD High Blood Pressu Hypertension Hpertension Pain/inflammation Pain/inflammation
Every Little Thing Brings BIG OUTCOMES. WellDyneRx is a full-service, independent Pharmacy Benefit Manager (PBM) that makes the little things matter for our clients, employees, partners, and members. Because we are an independent PBM meaning we are not owned by a pharmacy, drug company, or health insurance provider we are able to negotiate freely on your behalf to keep costs low and quality of care high for our clients and members. As early pioneers in clinical pharmacy, WellDyneRx has a history of caring for patients differently and always from a pharmacological perspective. We don t just fill prescriptions. We constantly monitor our clients claims and optimize our formularies to match members with treatments and clinical programs that are effective and economical. Most of all, our clients value the flexibility and customization they get with WellDyneRx. Whatever you need, we can create the right plan for you. Custom solutions for maximum flexibility, because everything we do on your behalf adds up for our clients and members. Every little thing brings big outcomes. www.welldynerx.com Drug Trend Report 2
Improved patient outcomes and lower costs are our specialty. In our wide variety of clinical programs has resulted in keeping overall trend to 1.2%, despite significant increases in utilization of specialty medications and double digit price inflation in many drug categories. Specialty medications account for almost 36% of overall spend but are attributed to only 0.8% claims. With a disproportionately large number of specialty pharmaceuticals in the pipeline, particularly targeted therapies in oncology, the specialty drug spend is anticipated to increase over the next several years. Our Intercept program, a strategic solution related to manufacturer copay cards, is designed to allow clients to mitigate these substantial increases without restricting access for these small patient populations with complex diseases. In, 48% of Intercept clients saw overall negative specialty trend despite increases in utilization. Overall, Intercept clients saw a 65% lower overall specialty trend than the 1.2% WellDyneRx book of business, and members saw a 60% cost-share reduction. According to the World Health Organization, increasing the effectiveness of adherence interventions may have a far greater impact on the health of the population than any improvement in specific medical treatments. US Specialty Care, winner of the Specialty Pharmacy Patient Choice Award, demonstrates excellence by driving medication adherence and specialty pharmacy patient and provider support. Our proven approach to drive medication OVERALL : WellDyneRx clients experienced an overall 1.2% increase in per member per year (PMPY) costs from 2016 to. adherence, identify and intervene on treatment issues, and improve provider care coordination through multiple touchpoints bolsters the percentage of patients who are adherent with their complex treatment regimens. www.welldynerx.com Drug Trend Report 3
WellManaged Clinical Programs Make all the Difference. Clinical pharmacy expertise is at the core of all WellDyneRx solutions. We offer an industry-leading array of clinical programs called WellManaged that perfectly balance optimal clinical outcomes with minimized plan costs. From offerings that effectively treat diabetes, to programs that reduce the risks associated with high dose opioid use, the WellManaged suite of clinical solutions are evidence-based and promote high quality care. Diabetes is the leading cost driver in traditional drug spend, for both large and small plans, accounting on average for more than 10% of total drug spend and these numbers continue to rise as the diabetes epidemic continues. WellManaged-Diabetes with Case Management, one of our new clinical programs rolled out in July, provides a comprehensive approach to diabetes patient care designed to improve overall patient outcomes while controlling costs. Our program helps clients better manage diabetes costs through improved medication adherence, aggressive cost containment through tight formulary management and therapeutic interchange initiatives, improved therapeutic outcomes through monitoring of key outcome measures, and increased communication with prescribers to better coordinate care. Comparing the first six months of to the last six months of the same year, our program has helped clients have a negative unit cost trend while increasing medication adherence and reducing hemoglobin A1c, the primary health outcome related to the management of diabetes. WellDyneRx is also helping clients advocate for the safe and effective treatment of chronic pain. The Centers for Disease Control (CDC) attributes the dramatic spike in opioid-related overdose deaths to prescription opioid pain relievers. The President declared a national emergency around the opioid epidemic, and for the first time since the 1960s, the CDC has decreased the overall life expectancy due to the large numbers of needless opioid-related deaths. Since 2014, WellManaged-Opioids has helped clients mitigate rising inappropriate opioid prescribing and use without preventing appropriate access to medications used to relieve pain. Clients who implemented WellManaged-Opioids in 2014 saw a 50% reduction in opioid prescribing, 46% less high risk utilizers, and 42% lower opioid per member per month (PMPM), in an environment with increased media, regulatory, and medical establishment scrutiny. Despite the increased awareness, the opioid issue remains prevalent and WellManaged-Opioids maintains access to these medications while prioritizing patient safety and controlling costs. www.welldynerx.com Drug Trend Report 4
Components of Trend Commercial plans saw per-person overall spending increase of only 1.2% Specialty experienced an increase in utilization due to expanded indications, new drugs to market, and large emphasis on moving specialty medications from the medical benefit to the pharmacy benefit, particularly Stelara and Remicade. Specialty accounted for 35.7% of overall spend in, an increase from 30.6% of overall spend in 2016. As expected, specialty spend will continue to increase as a percentage of overall spend due to new agents to market, expanded medications, and improved tolerability. Traditional unit cost decrease was driven by new generics in the highly utilized therapeutic classes of high blood pressure and high blood cholesterol. The Generic Dispensing Rate (GDR) across our clients increased from 82.68% in 2016 to 84.91% in. In addition to the new generics that came to market, this increase was augmented by over 30% of our clients who have implemented WellManaged- Generics. Many plans have implemented WellManaged-Opioids, which also helped drive a decrease in unit cost and utilization of opioid products, contributing to the decreases seen in the traditional spend. Plans that implemented WellManaged- Opioids in 2016 experienced a 27% reduction in utilization of opioids, 5.5% reduction in unit cost, and an overall opioid trend reduction of 31%. Utilization Unit Cost Total Trend Specialty 18.1% -0.2% 17.9% Traditional 0.4% -6.6% -6.2% Total 0.6% 0.6% 1.2% www.welldynerx.com Drug Trend Report 5
Top Drugs by Spend Diabetes accounts for half of the top 10 traditional drugs by spend, with both oral and injectable agents. New agents in existing diabetes drug classes, such as Ozempic and Steglatro, will allow for expanded price competition among comparable clinically equivalent agents. Generic Viagra, which became available in late, is expected to demonstrate significant decreases in unit cost in 2018. A shift from Cialis to generic Viagra is also likely to occur, particularly with clients who have implemented WellManaged-Generics. Medications used to treat in ammatory conditions account for 60% of the top specialty drugs by spend. Agents used to treat inflammatory conditions are expected to claim more top ten specialty spots in 2018. Utilization shifts in Hepatitis C treatment to less expensive Mavyret will likely displace Zepatier from the top 10 specialty drug list by spend. TRADITIONAL Rank Product Name Therapy Class 1 JANUVIA Diabetes 2 CIALIS Erectile Dysfunction 3 LANTUS SOLOSTAR Diabetes 4 LYRICA Pain/Inflammation 5 VYVANSE Attention Disorder 6 VIAGRA Erectile Dysfunction 7 VICTOZA Diabetes 8 INVOKANA Diabetes 9 SYMBICORT Asthma/COPD 10 TRULICITY Diabetes SPECIALTY Rank Product Name Therapy Class 1 HUMIRA PEN Inflammatory Conditions 2 ENBREL SURECLICK Inflammatory Conditions 3 STELARA Inflammatory Conditions 4 TECFIDERA MS 5 COPAXONE MS 6 HUMIRA Inflammatory Conditions 7 NORDITROPIN FLEXPRO Growth Hormone 8 ENBREL Inflammatory Conditions 9 ZEPATIER Hep C 10 OTEZLA Inflammatory Conditions www.welldynerx.com Drug Trend Report 6
Top 10 Therapeutic Categories Inflammatory conditions and diabetes are the predominant therapeutic categories, accounting for approximately 25% of overall drug spend in. Diabetes and Inflammatory conditions swapped positions from the previous year. This is largely due to the large increase in utilization of mediations in Inflammatory conditions with a shift from the medical to the pharmacy benefit. High Blood Cholesterol experienced a significant drop in rank, from number 4 in 2016 to number 9 in. This is due to the continued competition amongst statin agents, particularly reductions in spend for atorvastatin generic and the introduction of Crestor generic. Oncology moved up in the ranking from 7th place to 4th place, predominantly due to expanded indications for existing oncolytics, as well as several new chemical entities in, which drove double-digit increase in utilization. Benicar (olmesartan) and Crestor (rosuvastatin) generics significantly drove down unit cost in the high blood pressure and high blood cholesterol categories. Decreases in utilization of opioids and shifts to non hyper-inflated NSAIDs drove down trend for the pain/ inflammation category. Hepatitis C was not in the top therapeutic categories, driven largely by decreases in utilization and unit cost through our Hepatitis C Indication Based Formulary. HIV increased to rank 7 from previous year at rank 13. This is largely due to increased utilization of better tolerated agents with less side effects and drug-drug interactions. Rank Type Category PMPY Spend % OF TOTAL SPEND UTILIZATION UNIT COST TOTAL 1 Specialty Inflammatory Conditions $ 139.40 13.0% 22.8% 13.8% 36.6% 2 Traditional Diabetes $ 128.16 11.9% 3.6% 2.2% 5.8% 3 Specialty MS $ 51.44 4.8% -1.2% 6.9% 5.7% 4 Specialty Oncology $ 52.34 4.9% 20.6% 6.4% 27.0% 5 Traditional Asthma/COPD $ 46.44 4.3% 3.7% -2.5% 1.2% 6 Traditional High Blood Pressure $ 33.29 3.1% -0.3% -18.6% -18.9% 7 Specialty HIV $ 29.96 2.8% 13.8% 14.9% 28.7% 8 Traditional Pain/Inflammation $ 29.42 2.7% -7.3% -26.0% -33.3% 9 Traditional High Blood Cholesterol $ 28.91 2.7% -0.1% -38.8% -38.9% 10 Traditional Attention Disorder $ 27.60 2.6% 3.1% -3.3% -0.2% $ 506.57 47.2% -0.1% -3.9% -4.0% Total $ 1,073.53 100.0% 0.6% 0.6% 1.2% www.welldynerx.com Drug Trend Report 7
1. Inflammatory Conditions SPECIALTY CONDITION Humira and Enbrel products account for 60% of market share and experienced AWP increases nearing 10%, which contributed to both unit cost and overall trend increase in this category. While biosomilars for Enbrel and Humira have been approved by the FDA, due to ongoing patent litigation, it is unlikely they will enter the market in 2018 thus delaying potential price competition amongst agents. Stelara and Remicade experienced significant increases in utilizers due to increased benefit design change moving coverage from the medical to pharmacy specialty benefit. Utilization increase in this category is cut approximately in half from 22.8% to 11.8% if Stelara and Remicade are removed from the category. Dupixent, the first specialty drug for treatment of atopic dertatitis, saw significant utilization and is expected to increase in market share for the category for 2018. Dupixent has also filed with the FDA seeking expanded indication for asthma as add-on therapy. A decision is expected in late 2018 and could result in increase of utilization of this agent. Two oral agents for inflammatory conditions, Xeljanz XR and Otezla, experienced increases in utilization and market share. MARKET SHARE HUMIRA PEN HUMIRA STELARA ENBREL SURECLICK OTEZLA CATEGORY PMPY SPEND % OF TOTAL SPEND UTILIZATION UNIT COST TOTAL Inflammatory Conditions $ 139.40 13.0% 22.8% 13.8% 36.6% www.welldynerx.com Drug Trend Report 8
2. Diabetes TRADITIONAL CONDITION Diabetes was the highest cost traditional drug category, accounting for 11.9% of overall drug spend, with increases driven largely by unit cost inflation. Insulin agents, key drivers for diabetic trend, make up over 42% of diabetic drug spend and account for 18% of medication use. Metformin is the most utilized agent in the class, accounting for approximately 40% of medication use. Market share amongst the top 5 agents has seen negligible change from the previous year. Preferred formulations of metformin products, which have the same clinical effectiveness as other formulations, are 98% less costly. Aggressive formulary control of these metformin formulations resulted in a 58% unit cost decrease trend, which mitigated price inflation in brand diabetic drug classes. MARKET SHARE METFORMIN HCL METFORMIN HCL ER GLIMEPIRIDE LANTUS SOLOSTAR JANUVIA CATEGORY PMPY SPEND % OF TOTAL SPEND UTILIZATION UNIT COST TOTAL Diabetes $ 128.16 11.9% 3.6% 2.2% 5.8% www.welldynerx.com Drug Trend Report 9
3. Multiple Sclerosis SPECIALTY CONDITION Oral MS agents continued to dominate the market share, accounting for 52% of medication use and 48% of drug spend. Most injectable MS agents experienced decreases in trend driven by decreases in utilization, signaling a shift from injectable to oral agents. Decrease in overall utilization is likely driven by shift to Ocrevus, typically handled through the medical specialty benefit. In, Ocrevus reported significant revenue and is considered by many as an impressive launch for a new molecular entity in the market. US Specialty Care has access to dispense Ocrevus, and costs are typically lower when this drug is filled under the pharmacy benefit than the medical benefit. Increase in unit cost was driven largely by double-digit increases in oral agents, particularly Tecfidera and Gilenya. Our MS Center of Excellence at US Specialty Care helps drive adherence and improve patient and provider communication and assessment of outcomes. Adherence at US Specialty Care continues to outperform industry standards, with an average PDC among the MS patients of over 92%. MARKET SHARE COPAXONE AMPYRA TECFIDERA AUBAGIO GILENYA CATEGORY PMPY SPEND % OF TOTAL SPEND UTILIZATION UNIT COST TOTAL Multiple Sclerosis $ 51.44 4.8% -1.2% 6.9% 5.7% www.welldynerx.com Drug Trend Report 10
4. Oncology SPECIALTY CONDITION Oncology moved up in the ranking from 7th place to 4th place, due to double-digit trend, driven predominantly by double-digit increase in utilization. Increases in utilization is attributed largely to new drugs to market, particularly Rubraca, Zejula, Verzenio, Perjeta, Rydapt, and Kisqali. Increases in utilization were also attributed to expanded indications of several agents as first line agents, particularly for use in lung and breast cancer. Generic unit cost decreases for capecitabine and imatinib and significant increases in utilization, largely combatted increases seen with other agents. Drug mix, including increased use of available generic oncolytics, mitigated overall unit cost increase to only 5.3% despite double-digit unit cost increases in most branded agents. Targeted oncolytics have a better side effect profile and are better tolerated by patients, which results in slowing down disease progression with better quality of life and longer courses of therapy. MARKET SHARE CAPECITABINE REVLIMID IBRANCE TEMOZOLOMIDE RITUXAN CATEGORY PMPY SPEND % OF TOTAL SPEND UTILIZATION UNIT COST TOTA L Oncology $ 52.34 4.9% 20.6% 6.4% 27.0% www.welldynerx.com Drug Trend Report 11
5. Asthma / COPD TRADITIONAL CONDITION Overall trend held at 1.2%, despite multiple new agents introduced in the treatment for COPD in. Drug mix and unit cost decreases of generic agents montelukast and levalbuterol contributed to negative unit cost in a category with multiple brand products Market share in the combination ICS products saw the beginning of a shift away from Advair and Symbicort to the newer agents. Enhanced price pressure amongst brand agents will continue to drive unit cost down. WellManaged-Respiratory, launching in 2018, is a new clinical program designed to help improve quality measures and clinical outcomes around asthma and COPD while controlling costs. Due to the multitude of similar clinically effective regimens in this category, the WellManaged - Respiratory program will include an aggressively managed formulary, adherence interventions, and patient education to ensure optimal clinical and financial outcomes. MARKET SHARE MONTELUKAST ADVAIR DISKUS SYMBICORT VENTOLIN HFA PROAIR HFA CATEGORY PMPY SPEND % OF TOTAL SPEND UTILIZATION UNIT COST TOTAL Asthma/COPD $ 46.44 4.3% 3.7% -2.5% 1.2% www.welldynerx.com Drug Trend Report 12
6. High Blood Pressure TRADITIONAL CONDITION Approximately 50% of all medications utilized for high blood pressure are low-cost and highly effective generic medications. Significant unit cost decreases of generic Benicar (olmesartan) and Benicar combination products resulted in significant unit cost and overall trend reductions coupled with large increases in olmesartan utilization and decreases in brand Benicar. Utilization is expected to increase in 2018 due to recent release of updated guidelines from the ACC/AHA expanding the number of patients who should be treated compared to previous years. Approximately 22% of all high blood pressure agents experienced double-digit unit cost decreases, which contributed significantly to overall unit cost and trend reductions in this category. MARKET SHARE LISINOPRIL AMLODIPINE LOSARTAN HCTZ METOPROLOL SUCCINATE ER CATEGORY PMPY SPEND % OF TOTAL SPEND UTILIZATION UNIT COST TOTAL High Blood Pressure $ 33.29 3.1% -0.3% -18.6% -18.9% www.welldynerx.com Drug Trend Report 13
7. HIV SPECIALTY CONDITION HIV as a therapeutic category rose 6 spots from 2016, from 13th to 7th based on PMPY. It also accounted for a larger portion of the total drug spend, Continued media attention Continued shift from the tenofovir disoproxil fumarate (TDF) for expanded prescribing and formulations to the tenofovir alafenamide (TAF) formulations coverage for pre-exposure contributed to the unit cost increases in this category. TAF formulations, prophylaxis may particularly Genvoya, Odefsey, and Descovy, experienced significant also have contributed to increases in utilization. increase in utilization. Truvada saw significant increase in utilization and market share in. Several new agents in 2018, such as Biktarvy and Trogarzo, are expected to impact this category. Despite FDA-approval for generic Truvada in, it is unclear when it will be commercially available due to ongoing patent litigation and negotiations. MARKET SHARE TRUVADA GENVOYA ATRIPLA STRIBILD TRIUMEQ CATEGORY PMPY SPEND % OF TOTAL SPEND UTILIZATION UNIT COST TOTAL HIV $ 29.96 2.8% 13.8% 14.9% 28.7% www.welldynerx.com Drug Trend Report 14
8. Pain/Inflammation TRADITIONAL CONDITION Pain/Inflammation shifted from 6th place in 2016 to 8th place in, driven mostly by significant decreases in unit cost as well as utilization. Inappropriate prescribing of opioids, particularly transmucosal immediate-release fentanyl (TIRF) and long-acting agents, were key drivers in decreases associated with the WellManaged-Opioids program. Members in groups that were not managed showed a 36% higher average cost per 30-day supply of opioid medication. Unit cost decreases were largely due to expanded implementation by clients of WellManaged-Opioids and our Hyperinflationary Drug List. Preventing utilization of hyperinflationary medications, such as Duexis or Vimovo, which have readily available alternatives at substantially less cost were key drivers in decrease in unit cost for the Hyperinflationary Drug List program. MARKET SHARE HYDROCODONE / APAP MELOXICAM OXYCODONE / APAP IBUPROFEN TRAMADOL HCL CATEGORY PMPY SPEND % OF TOTAL SPEND UTILIZATION UNIT COST TOTAL Pain/Inflammation $ 29.42 2.7% -7.3% -26.0% -33.3% www.welldynerx.com Drug Trend Report 15
9. High Blood Cholesterol TRADITIONAL CONDITION High blood cholesterol experienced the largest shift, with a drop from 4th most expensive to 9th. Significant decreases in unit cost drove the almost 39% decrease in trend in the category, driven largely by new to market generics for Zetia and Vytorin. Over 77% of the utilization in this category was for generically available statins, with atorvastatin at almost 40% of the market share. WellManaged-Generics aggressively managed utilization away from brand Crestor to its generic rosuvastatin, further driving down unit cost in the category. Non-statin therapies decreased from the previous year and comprise a small percentage of overall use. Updated ACC/AHA Cholesterol treatment guidelines are slated to be released in 2018, which may have further impact on utilization patterns in this category. MARKET SHARE FENOFIBRATE ATORVASTATIN PRAVASTATIN ROSUVASTATIN SIMVASTATIN CATEGORY PMPY SPEND % OF TOTAL SPEND UTILIZATION UNIT COST TOTAL High Blood Cholesterol $28.91 2.7% -0.1% -38.8% -38.9% www.welldynerx.com Drug Trend Report 16
10. Attention Disorder TRADITIONAL CONDITION New generics for Strattera (atomoxetine) and increased generic price competition among guanfacine ER, armodafinil, and modafinil contributed to decreases in unit cost. WellManaged-Generics helped drive generic utilization in this category, with 4 out of the top 5 as generic agents. Overall in the category, the generic dispensing rate (GDR) was 75%, an increase of almost 5% from the previous year. It is estimated that for every 1% increase in generic dispensing, there is approximately 4% in savings. MARKET SHARE METHYLPHENIDATE AMPHETAMINE/ DEXTROAMPHETAMINE GUANFACINE ER METHYLPHENIDATE ER VYVANSE CATEGORY PMPY SPEND % OF TOTAL SPEND UTILIZATION UNIT COST TOTAL Attention Disorder $ 27.60 2.6% 3.1% -3.3% -0.2% www.welldynerx.com Drug Trend Report 17
Methodology Trend: Represents change for Total Costs PMPY (total plan and member pay) for from 2016 for WellDyneRx commercial book of business and is net of rebates. Utilization: Represents the change in day supply PMPY year over year. Unit Cost: Represents the change in Total Cost per day supply year over year, net of rebates received by plans. About WellDyneRx WellDyneRx is a full-service Pharmacy Benefit Manager (PBM) that makes the little things matter for its clients, employees, partners, and members. WellDyneRx provides members with more than 66,000 retail pharmacies across the U.S.; mail order prescription services with the capacity to fulfill more than 15 million prescriptions per year; a wholly-owned specialty pharmacy (www. USSpecialtyCare.com) to focus on expensive specialized drugs; and highly targeted pharmacy programs for Diabetes, Hepatitis C and Opioids to balance optimal clinical outcomes with minimized plan costs. Visit www.welldynerx.com to learn how you can optimize your health plan today. Note: Plans were excluded if they were not clients for all of 2016 and or if they had 100% or 0% copayment benefits. Minimum essential coverage (MEC) clients were also excluded. In most cases, results are rounded down to one decimal for easier reading. www.welldynerx.com Drug Trend Report 18