The Future of Biologics in Part D

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The Future of Biologics in Part D

• Eric Toppy
• Director of Marketing Strategy
• Payer, Policy and Emerging Markets
• Centocor Ortho Biotech Services, LLC

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Disclaimer

• The following content and opinions do not
  necessarily reflect the views and Opinions of
  Centocor Ortho Biotech Services, LLC

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Medicare
Source political cartoonist.com
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Part D- A Success Story
Part D
Sources WSJ-July 5, 2005 The Hill. com -Jan 11,
2007
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Success Defined
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Success Defined
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Choice..ChoiceChoice
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Where are they?
Source Kaiser Family Foundation
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The Gap
Source Kaiser Family Foundation
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D Impact on Biologics

• Sub-Q Growth
• Accelerated Commoditization
• Multiple Customer Benefits
• Consumers
• Physicians
• Payers
• Membership growth
• Rebate Revenue

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The Benefit
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Donut Hole

• The Donut Hole in Part D is..
• Local establishment where MA-PD enrollment occurs
• A New diet craze sweeping the nation
• Patient who pays TROOP of 4,000
• Place that most beneficiaries dont visit due to
  pressures of competitive marketplace-gap coverage

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Commercial Part D Programs

• Cafeteria Plan
• Open Closed Formularies
• Two Markets
• Drug Benefit Naïve
• Part D switch
• Adverse Selection

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Biologics Health Plans

• Consumer Choice
• CMS recommendations
• Minimal benefit offering
• PT Product Review Timing
• Part B vs. Part D
• Physician vs. self administered
• Medical Education Reimbursement
• CAP Program

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CMS 2009

• Health Plans to post drug formularies
• BIO Position- All information that includes step
  edits, prior authorizations, quantity limits
• Continuation of Specialty Tiers
• BIO position- Impact on Patient Affordability
• Home Health Care Reimbursement
• 2009

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Possible Threats to Biologics in Part D

• Back to the Future
• Reduction in Part D payments
• Elections
• Reference Pricing
• BioSimilars
• Comparative Effectiveness-AHRQ
• Employer Shift Increased MLR

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The Future of Biologics and Part D

• Biomarker/Genomics
• Competing Govt needs
• Reward for Innovation?
• EMRs
• Pay for Performance
• Report Cards
• Small Molecule Biologics

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Thank You and Questions