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The Future of Biologics in Part D

Explore the impact of Part D on biologics, including sub-Q growth, multiple customer benefits, and the "benefit" donut hole. Discover the role of health plans, consumer choice, and potential threats such as reference pricing and BioSimilars.

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The Future of Biologics in Part D

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  1. The Future of Biologics in Part D Eric Toppy Director of Marketing Strategy Payer, Policy and Emerging Markets Centocor Ortho Biotech Services, LLC

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

  3. Medicare Source: political cartoonist.com

  4. Part D- A Success Story Part D Sources: WSJ-July 5, 2005 The Hill. com -Jan 11, 2007

  5. Success Defined

  6. Success Defined

  7. Choice..Choice…Choice

  8. Where are they? Source: Kaiser Family Foundation

  9. The Gap Source: Kaiser Family Foundation

  10. “D” & Impact on Biologics • Sub-Q Growth • Accelerated Commoditization • Multiple Customer Benefits • Consumers • Physicians • Payers • Membership growth • Rebate Revenue

  11. The “Benefit”

  12. 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 don’t visit due to pressures of competitive marketplace-gap coverage

  13. Commercial Part D Programs • Cafeteria Plan • Open & Closed Formularies • Two Markets • Drug Benefit Naïve • Part D switch • Adverse Selection

  14. Biologics & Health Plans • Consumer Choice • CMS recommendations • Minimal benefit offering • P&T Product Review Timing • Part B vs. Part D • Physician vs. self administered • Medical Education Reimbursement • CAP Program

  15. 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

  16. 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

  17. The Future of Biologics and Part D • Biomarker/Genomics • Competing Gov’t needs • Reward for Innovation? • EMRs • Pay for Performance • Report Cards • Small Molecule Biologics

  18. Thank You and Questions

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