Bob Carta, Vice President, Division of Pharmacy Services, Carolinas HealthCare System, Cole Wilson, AVP Outpatient Pharmacy Services for Carolinas HealthCare System and Terry McInnis, MD, President of Blue Thorn Inc. discuss medication adherence and the specialty drug space as it relates to employer healthcare costs. Part 2 of 3. Cole Wilson Opportunities to Ensure Delivery of the Value Promise for Specialty Patients

1. Opportunities to Ensure Delivery of the
Value Promise for Specialty Patients
September 15, 2017
Cole Wilson
AVP Outpatient Pharmacy Services

2. What is a Specialty Drug?
• Specialized Prescription Processing
(prior auth, formularies, patient
financial support)
• Comprehensive clinical support
(drug administration, side effect
management, drug interactions)
• High Cost ($500+ per dose or
$100,000 per year)
• Manufacturers and Payers limit
access to qualified partners

3. Specialty Drug Spend
• Specialty patients represent 3% of the US population
• In 2016, specialty drug spend was $180 billion (40% of total drug spend)
Oncology,
$46.8, 26%
Automimmune,
$32.4, 18%
HIV, $21.6,
12%
MS, $19.8,
11%
Other, $41.4
23%
Total 2016 US Specialty Drug Spend ($180 billion)
Hepatitis,
$18, 10%
• 60% increase in specialty drug
spend over the last five years
• 2020 estimates suggest that
specialty spending could reach
$400 billion
• 9.1% percent of national
health spending

4. 21% Specialty CAGR
2% Non-Specialty CAGR
Disproportionate Specialty Growth
Specialty drug spend is growing disproportionately to non-specialty drugs and most
other service lines. Payers are developing strategies to control specialty costs,
knowing that savings earned today are likely to quadruple over the next five years.
$-
$100
$200
$300
$400
$500
2012 2020
U.S. Drug Spend, 2012-2020
($ billions)
Specialty drug spend Non-specialty drug spend
Source: UnitedHealth, “The Growth of Specialty Pharmacy”, April 2014.

5. Specialty Drug Industry – Specialty Drugs

6. Specialty Drug Industry – Manufactures

7. Specialty Drug Industry – Payers

8. Specialty Drug Industry – Specialty Pharmacies

9. Challenges for Specialty Patients
• Concerning health condition
• Confusion and anxiety
• Concerns with cost of therapy
• Managing treatments and
side effects

10. Challenges for Provider Team Treating
Specialty Patients
• Time and resources demanded by
specialty conditions
• Starting patients ON therapy
• Helping patients STAY on therapy
• Connecting with patients
BETWEEN practice visits
• Quality metrics and outcomes
performance for patient care

11. Challenges for Specialty Payers
• Complexity of controlling the
high cost of specialty
conditions
• Avoiding negative impact on
patient outcomes
• Navigation burden &
affordability
• Avoiding negative impact on
providers
• Administrative burden &
clinical protocols

12. Provider
CHS Specialty Pharmacy Service Learnings
Hospital Pharmacy
Outpatient Pharmacy
Retail Rx
Drug Manufacturer
Drug Manufacturer
Patient Support
Services
Ancillary roles (navigator,
financial counselor, social worker) Employer
Payer
Prior Auth. Process
Foundation
Support
“Outside” Specialty
Pharmacies
RN/MOA/Staff
Patient

13. CHS Specialty Pharmacy Service
Learnings “The Challenge”
When will we be expecting drug to arrive in the pharmacy?...So, we don’t need that info sheet filled out?…This is a problem….I have XXXXX reaching out to XXXXX to find out why this has
occurred….This info has to be filled out, and signed by the prescribing doctor, in order to order the XXXXX…we have been ordering this drug in the past, but he said this restriction is
something new…Most likely, we will not get this product tomorrow when patient is coming in for her infusion. How do you want us to proceed with this? When you have a moment can
you check to see if we have access to XXXXX. This drug is manufactured by XXXXX and is used for plaque psoriasis. Dr. XXXXX with Dr. XXXXX office is asking…This to me indicates we
currently don’t have access…. NC Medicaid doesn’t have the drug loaded into their system yet but I will keep trying to get a paid claim over the next few days…. I have a patient who was
previously on study now needed XXXXX...do we have a faster/easier time of getting given our AZ contacts? …Spoke to XXXXX Rx (the pharmacy benefit manager) they still do not have the
drug loaded, they could not give an ETA. We will continue to follow up daily and will update office once we show drug is loaded…. RN needs to know the strengths available to pass along
to Dr XXXXX I can’t find anything on the internet and neither could pharmacist. Please get back to me ASAP RN is waiting!!!!!.. Here is the package insert for a drug Dr. XXXXX has asked us
to look in to. It needs to be kept frozen until 30 minutes prior to injecting, it is injected by the provider so it seems like it might be medically billed…. Spoke to a rite aid and they too do
not have drug. Talked with patient and we are going to get drug to him today via hospital courier…. Dr XXXXX would like patient to start XXXXX 1mg/kg BID immediately. Can you please
do a STAT benefits investigation? I am waiting for confirmation of how many syringes to order, then I will send script electronically. Thank you for your help!... Provider is switching all
XXXXX patients to XXXXX. This drug is currently only offered at XXXXX. WE NEED DRUGACCESS!!!!... Outside pharmacy called the patient back and told them we were not refilling his
medication and the wife is now calling us concerned about why we aren’t continuing the medication. Can you please follow up with someone there regarding this?... RA office sent me a
message stating that they have had several patients think that the starter kit (talking pen) is actual medication. They have been putting this in the fridge with the real drug and in some
cases just bringing the talking pen to appointment for injection training?!?!?!... Is it possible for you to transfer the prescription and fill it and also deliver the medication while patient is
in infusion?... This patient's PA was denied. Who would you like me to contact regarding an appeal?...Provider wants Pharmacy to assist with adverse event management of this new
drug…. i was just told that Kmart specialty pharmacy visited LCI concord and is trying to sell their business. their big selling point is they do PAs. How?…. Patient is so anxious about
starting medication…. It was a Medicare Part B that was stuck in Error Resolution and it did not populate our QA for us to look at when we do our 6pm rundown…. . The issues is that
Medicaid has 2 systems and Medicaid still needs to update 1 of the 2 systems which could take another week or so…. To finish up his treatment (which again, is likely to be curative), he
needs a 30-day supply of XXXXX , and the copay is apparently in the $5000 neighborhood. He is unable to afford this, and we have been unable to find the patient any help through
foundations, etc. Are there any resources through CHS that may be available to the patient?... Dr. XXXXX wants to know when XXXXX will be loaded into Cerner. He wants it in there
ASAP!... patient of Dr. XXXXX with APL. He is currently on XXXXX and XXXXX treatment. He is having some issues with his insurance as he just recently lost his current insurance. He did
apply for new insurance through the Affordable Healthcare Act but it will not kick in until May 1. He just restarted his XXXXX medication and only has 3 days left of this medication. Can
you help us please?... I sent en enrollment to the Hub and they sent the Rx to an outside specialty pharmacy because they said we did not have access…The Cobra check was sent out on
April 10th from our AP team. Unfortunately it has to go to Arkansas so it is taking longer than anticipated. I am following his account daily so I will be sure to let you know when everything
is posted and insurance is reinstated…. New RN mistakenly sent a XXXXX script to an outside specialty pharmacy and to manufacture HUB (who also did not think of CHS SPS). The patient
wound up paying $2600.00 when he should have paid no more than $30….because prescriptions had to be sent to an outside specialty pharmacy, patient is going to be a week late on
treatment and is asking if there is anything we can do. She also wants to know if you can get access to it so we can dispense it… There are many clinical steps that the patients have to
complete in order to start XXXXX. Once the insurance information, (#4 on the profile sheet) has been submitted to the manufacturer HUB and the benefits are verified the patient will be
triaged to CHS SP after FDO completion. Please submit the insurance information to the manufacturer HUB if you have not already once you see that the PA has been approved and once
the patient completes FDO the triage will be sent to CHS from the manufacturer HUB…. If we had access “clean fill” 24-48 hrs, “dirty 48-72 hrs depending on how long the PA takes…. just
talked to patient to set up delivery and she requested us to have script sent to an outside specialty pharmacy… Our provider has about 20-25 Hep C patients and all are wanting to receive
the medications. We are getting so much information from drug companies our heads are spinning. Can you help or put us in touch with a source to help us figure this process out and
what we need to be doing?... Any luck finding his completed and signed CMS packet to include 5 pages (XXXXX Temporary PA form and beneficiary readiness eval)?... CHS SPS has been
trying to order XXXXX since last Thursday and distributer saying they don’t have the drug? Not sure what that is about. Checking on distributer website and they have 0 on hand. Last
week they had 9…. I am in need of more patient handouts when you can send them to me…. So I have been back on the phone with Cigna because the pharmacy can’t run the script
through. They say the PA that was done on the 19th was denied since this is a part D plan. I told them I know and this is also an Advantage plan that covers both. I am on hold with the
medical side know…As of 10/1/14 the manufacturer XXXXX copay card has ended due to generic availability. If a patient has a card active before this date it will still work, however no
one will be able to activate a copay card for XXXXX from now on…. Could you possible get a list of the pts’ prescribed Hep C treatment for the last six months per CHS practice
manager?….
“STAT benefits
investigation”
“Patient is so anxious”
“This is a
problem”
“Prior Authorization was denied” “Rx stuck in
error resolution”“Patient copay is apparently
in the $5000 neighborhood”
“He wants it in there ASAP”
“issues with
his insurance”
“patient is going to be a week late on treatment
and is asking if there is anything we can do”
“On hold for over an hour”“Left patient a message
for the second time”
“only has 3 days left of this medication”
“NEED DRUG
ACCESS!!!”

14. CHS Specialty Pharmacy Service Learnings
Specialty Pharmacy – New Prescription Process Flow

15. CHS Specialty Patient Care Value Promise

16. CHS Specialty Patient Care Value Promise
Integration and Outcomes
Data
Patient Management
Dispensing
Processing
Coordination of Care
(prior authorization,
benefits investigation,
financial assistance,
speed of medication
delivery)
Focus on treating
patients, not filling
prescriptions
Ability to evaluate
adherence to
evidence-based
standards and
effectiveness of care
Operational
efficiency for
providers and staff
Continuity of patient
monitoring and
follow up care
Clinical protocols
developed by
providers who use
them
Complete electronic
medical record
Communication and
flow of information

17. CHS Specialty Patient Care Value Promise
Coordination of Care
(prior authorization,
benefits investigation,
financial assistance,
speed of medication
delivery)
Focus on treating
patients, not filling
prescriptions
Ability to evaluate
adherence to
evidence-based
standards and
effectiveness of care
Operational
efficiency for
providers and staff
Continuity of patient
monitoring and
follow up care
Clinical protocols
developed by
providers who use
them
Complete electronic
medical record
Communication and
flow of information
A patient-centric, integrated
service and clinical care team
model that produces superior,
demonstrable results for
patients with complex, specialty
health conditions is the core
CHS value promise for
patients, providers, payers,
plan sponsors,
manufacturers and other
partners.

18. What Are Key Specialty Metrics that Can
Demonstrate the Value for an IDN?
Patient Satisfaction
• Patient surveys & stories
Provider Satisfaction & Efficiencies
• Patient surveys & stories
Copay Assistance
• Amount of copay assistance secured
• Mitigates key obstacle to therapy
• Valued by drug manufacturers
Time to Therapy
• Time from CHS SPS receiving Rx to
shipping to the patient
• Directly affects outcomes
Adherence
• Days patient possessed medication vs.
days in treatment regimen
• Directly affects outcomes
Clinical Outcomes
• Answers “is the therapy working?”
• Varies by disease state
Other Results
• Patients served & Rx’s filled
• Other Identified Health System goals
Demonstrating value is key for IDNs and their partners in care

19. Adherence makes a difference
for everybody…
Drug Adherence
BARACLUDE 80%
DAKLINZA 100%
ENTECAVIR 100%
HARVONI 98%
INTRON 100%
OLYSIO 100%
RIBAPAK 100%
RIBAVIRIN 97%
SOVALDI 98%
VIEKIRA 96%
ZEPATIER 100%
All Hepatitis Drugs 97%
Physician Adherence
BARACLUDE 100%
DAKLINZA 100%
HARVONI 100%
RIBAPAK 100%
RIBAVIRIN 95%
SOVALDI 100%
VIEKIRA 93%
ZEPATIER 100%
All Drugs for Dr. Who 99%
Dr. Who
Patient Drug Pre-Treatment SVR Post Treatment SVR Adherence
Doe, Jane RIBAVIRIN 3.9 MIL IU/ML HCV RNA undetectable 94%
Doe, Jane SOVALDI 3.9 MIL IU/ML HCV RNA undetectable 97%
Doe, John HARVONI 5.3 MIL IU/ML HCV RNA undetectable 97%
Disease Adherence
Oncology 87%
RA/DERM/GASTRO 93%
Hepatitis 97%
Multiple Sclerosis 94%
All Diseases 95%
Especially for the
patients that
experience superior
outcomes!

20. CHS SPS Adherence*
• Adherence directly affects clinical outcomes & treatment cost
• CHS SPS collaborative care model produces superior adherence
Sources: “Multiple Sclerosis: New Perspectives on the Patient Journey”; Milliman, April, 2016. “High-cost hepatitis C pill sees 8% non-adherence rate”/CVS Health Study; HealthIt Analytics,
September 18, 2014. “Adherence and resource use among patients treated with biologic drugs: findings from BEETLE study”; Clinicoecon Outcomes Res. 2014;6: 401 – 407. Leading RA drug mfg.
internal adherence data. “Specialty Pharmacy Improves Adherence to Imatinib”; Am J Pharm Benefits 2013 (Special Issue):SP33-SP39
* Adherence calculated using Medication Possession Ratio (MPR) - % of patients meeting respective therapy targets

21. Time to Therapy
• Industry survey 74% filled in fewer than 10 days but up to 20 days reported
• Better time-to-therapy leads to better outcomes
Sources: “Speed-to-Therapy Insights in Specialty Pharmacy”; Specialty Pharmacy Times, November 2013.
Survey
Avg.
(N=105)

22. IDN RA Outcomes Results
CHS SPS unique care model delivered 11% greater improvement and 17% less deterioration
CHS SPS performed RAPID3 assessments in collaboration
with providers creating efficiencies & improving outcomes

23. CHS SPS Hepatitis C Results
CHS SPS unique care model delivers industry-leading
treatment success and avoids cost of re-treatment
Patients managed by CHS SPS are 4 times more likely
to have viral load checks monitored and recorded in the EMR.
Re-treatment = $95,000
Liver Transplant = $739,000
High Cost of Failure
“Undetectable
Viral Load”
(253 Patients)

24. CHS SPS Copay Assistance Facts
On average, CHS SPS secured copay
assistance that paid for 85% of patient
copay vs. industry of 60%. Overall,
CHS SPS patients paid an average
copay of $29 per prescription.
0%
20%
40%
60%
80%
100%
120%
0
1000
2000
3000
4000
5000
6000
7000
Avg. Price / Rx Insurance Copay Assist Copay
Specialty Rx withCopay Assistance
Avg. Price / Rx % Paid
$5950
$5364
$566
$20
CHS SPS secured copay assistance for
qualified prescriptions, of which
patients paid an average of $20 per
prescription (97% reduction)
Copays are often obstacles
to starting & staying on therapy.
Poor adherence increases treatment failure
& re-treatment cost.
Sources: “Specialty Drug Coupons Lower Out-of-Pocket Costs and May Improve Adherence at the Risk of Increasing Premiums”; Health Affairs October 2014 33:101761-1769.
CHS SPS Specialty Coupon Utilization Jan16 thru Jun16.

25. Select CHS SPS Copay Assistance Facts
$800
$6
$1,328
$5
$530
$6
$520
$1
Disease Result
Hepatitis 35% $25,903
99.6%
Reduction
% of Rx
w/Assist
Avg. Price
Oncology
99%
Reduction
30% $8,602
Multiple Sclerosis 64% $5,948
99.8%
Reduction
RA/Derm/Gastro 68% $4,188
99%
Reduction
Avg. Copay
Key Therapies
Source: CHS SPS Specialty Coupon Utilization Jan16 thru Jun16.

26. What Have We Learned at CHS Specialty
Pharmacy Service “The Reward”
Distributer now says that we are good to go. The shipment is scheduled to arrive tomorrow morning via FedEx by 10:30am EST…. We appreciate all that you and your
staff do to assist us each day…. During the scariest time of his life, he is faced with medications that he can now afford with no Medicare Part D coverage. …. We have
access now to sign patients up for copay card for XXXXX through an online portal…. The patient was approved for the 30 day voucher assistance and will get drug
Friday…. I have always heard how amazing you all are…. I appreciate your help…Thanks for your help. This med is always hard….Awesome job…The PA has been
approved. The patient has a copay of $277.60. I was able to get him assistance with XXXXX Foundation for $6,000.00…. . It’s so great to see our collaboration grow into
such a tangible, lean process…. the claim went through for a copay of $2,615.77. I spoke with both the patient and husband and based on household size and income I
was able to secure $7500.00 in assistance from PANF so the patient will have a copay now of $0…The medication is leaving our pharmacy today and patient will receive
medication tomorrow….the medication arrived two days later, the process was expedited in a highly professional manner. When it comes to words, there is one very
special phrase that everybody can bank on. That is the simple, but powerful expression “thank you”…. I am so thankful that we were able to restart my son’s medication,
and at the same time receive financial assistance from the Patient Access Network Foundation…Thanks so much for your pleasant voice and patient attitude over the
phone during our phone calls this week. You were so helpful working to resolve a stressful situation for our family…. I just got the override in place to allow CHS SPS to
fill the XXXXX for a $10 copay. Due to the circumstances we are willing to take the risk this time. Dr. XXXXX, can you please e-scribe a prescription to our pharmacy. Also
we are able to deliver the med bedside today in rehab. Please provide room number…. As usual, CHS SPS is an all-star… Wow! Thank you !You guys always go above and
beyond for our patients (my nurses tell me so all the time). Thank you!... AWESOME work!! You guys rock!!... I spoke with the patient again and he finally gave me a
ballpark figure for his income. With that information I was able to obtain assistance through PANF in the amount of $7500.00. Our pharmacy is ordering the medication
and it should arrive tomorrow around 11am directly from the manufacture. The patients copay is $0. If he is still on campus we will deliver to him bedside tomorrow,
and if he has been discharged we will STAT currier the package to his house…. Dr. XXXXX, attached is the Free Trial offer for XXXXX. Please let me know if CHS SPS can
help in any other way…. Thanks sooooo much for all that you do!! I seriously could not do my job like I need to do it if I didn't have the assistance of CHS SPS. I am
thankful for you guys everyday…. I just wanted you and your staff to know how honored I have been to work with you all. A true sign of a professional is someone who
sees a need, takes the leap and makes something good. That is what you and your staff have done with the specialty pharmacy at CHS SPS. There is not another
department that I have worked with in almost 23 years that has made my job easier every time I called…And thanks so much for helping Mr. XXXXX get assistance. He’s
one of my favorite patients, and I really try to look out for him.. and when I heard his copay was so much, I felt so bad…CHS SPS expedited patient medication for $0 so
he could be discharged from the hospital on Friday, and not have to wait for his meds to be delivered a week later!... Thank you so much for all of your help with XXXXX
and his medication, the patient received the medication today! Thanks for always making my job much easier and answering my crazy emails and phone calls!...
Pharmacists work directly with doctors. They bridge the gap between the patient and the physician – and when you’re dealing with a life-and-death illness, that’s
priceless…. CHS SPS really went above and beyond the call of duty. They researched financial aid opportunities and helped us fill out the paperwork, which ultimately
saved us a substantial amount of money. They were able to help us in ways retail pharmacies can’t…CHS patient initial copay $2000.00 on XXXXX tried PANF for RCC
assistance, funding closed went to manufacturer HUB 7 days later they noted PANF open I call and 15 min later $7500.00 approved patient still getting med 7 days
before start date…. XXXXX sent to CHS SPS today and coordinated through outside specialty pharmacy to secure drug to patient tomorrow (sat) instead of Tuesday, with
a $0 copay…CHS SPS received a prescription for XXXXX for a patient from Dr. XXXXX. Patient went to Wal-Mart to fill and has no insurance cash price was $150.00 patient
needs to start and could not afford. RN called and asked if I could help, our cash price is $14.67. Called patient and she was thrilled she could afford that and will get
medication tomorrow…PA just got approved $0 copay and patient will have med tomorrow…. We are saving the patient about 1800.00 per month…. Patient at rehab
needs specialty medication ASAP. Patient should be discharged by end of week (8/10/12) and assistance will be in place by discharge….. Patient is able to start tonight
while inpatient with an original $50 co pay that we brought down to a $10 co pay with available co pay card…. Patient had $120 total copay and after getting assistance
through manufacturer patient now pays $0. Since CHS SPS were so quick in turnaround patient start date for radiation can be 7 days earlier!... Thank you guy’s for the
quick response and resolution!... Dr. XXXXX just said you are a Miracle worker! …You guys are GREAT GREAT!!!... Thank you so much for getting the specialty meds out
today to our patient! We are amazed on how quick this process was and couldn't believe the patient already received his meds! I just wanted to say thank you for your
help not only with this patient but with all of our patients!...Practice initially sent patient to local pharmacy for XXXXX. Patient was told $1700.00 copay. RN rerouted Rx
to CHS SPS for patient assistance. Patient copay reduced to $3….Nurse wishes she called CHS SPS first before trying to find medication locally would have saved her
hours!... RN thinks we saved her at least a week in turn around time….
“improved outcomes” “Prior authorization
has been approved”
“A true sign of a professional is someone who sees a
need, takes the leap and makes something good”
“pleasant voice and right patient attitude”
“Dr. XXXXX just said you are a
Miracle worker!”
“Nurse wishes she had called CHS SPS first”
“Patient copay reduced to $3”
“I seriously could not do my job like I need to do it if I
didn't have your assistance”
“bridge the gap between the
patient and the physician”
“couldn't believe the patient
already received his meds”
“thank you for your help not only with
this patient but with all of our patients”
“Saved us so much time”

27. Thank you.