Managing High Cost Specialty Medications Pharmacy Benefits Policy Making for Vulnerable Populations

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Managing High Cost Specialty Medications-
Pharmacy Benefits Policy Making for Vulnerable
Populations

• October 31, 2005
• Catherine D. Pappas, Pharm.D.
• Director of Pharmacy
• Neighborhood Health Plan

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Traditional vs Specialty Therapy

• Traditional
• Less effort to remain compliant with therapy
• Failure to comply may lead to adverse outcomes
  and increased health care costs
• Daily routine usually does not require change to
  accommodate drug administration
• Side effects are usually less severe and fewer
• Less education needed regarding administration
  and storage

• Specialty
• Significant effort to remain compliant with
  therapy
• Failure to comply results in adverse outcomes and
  increased health care costs
• Often requires lifestyle changes for patient and
  caregiver(s)
• Side effects are usually more frequent and more
  serious
• Requires ongoing one to one patient support
• Significant education needed regarding
  administration and storage

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Biotech Landscape

• 324 Biotechnology Drugs in the Pipeline

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Pipeline Activity for Leading Specialty Drug
Categories
Source SG Cowen 3/05
Source Express Scripts data, October 2005
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Routes of Administration Specialty Drug
Pipeline

• Late-stage development
• Phase II or later
• Majority are injectable

Source Express Scripts data
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Routes of Administration Specialty Drug
Pipeline

• Late-stage development
• Phase II or later
• Majority are injectable

Source Express Scripts data
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Three Types of Specialty Drugs

• Self-Administered Drugs
• Clinic/Office Administered Infusables
• Office-Administered Chemotherapy

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Stages of Specialty Medication Management

• Stage 1 Buy and Bill
• Stage 2 Specialty pharmacy (SP),
  self-administration and reimbursement changes
• Stage 3 Category narrowing and preferred
  products
• Stage 4 Benefit design and cost-sharing
  innovation
• Stage 5 Genomic diagnostics and genetic risk
  management

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Case Study Management of Omalizumab (Xolair)

• Jim Glauber, MD, MPH, FAAP
  Medical Director, Neighborhood Health Plan