Pharmaceutical Coalition Transparency in Pharmaceutical Purchasing Solutions (TIPPS) Initiative

1. Pharmaceutical CoalitionTransparency in Pharmaceutical Purchasing Solutions (TIPPS) Initiative April 10, 2008

2. Leadership & Staff • Sidney BanwartVice President, Human Services Division, Caterpillar, Inc.Chairman, Pharmaceutical Coalition • Clay ElwardCaterpillar, Inc. • Darin HindermanCaterpillar, Inc. • Marisa MiltonHR Policy Association • Steve WetzellHealth Care Policy Roundtable

3. Hewitt’s Project Support • Joshua Golden National TIPPS Project Leader • Kristin BegleyNational Pharmacy Practice Leader

4. Today’s Discussion • Closed Sessions • Review TIPPS Standards & Objectives • Lessons Learned • Refining TIPPS Standards and Objectives for 2009 • TIPPS + Pricing Concept • Open Sessions • 2009 TIPPS Process • Managing Pharmacy for the Future • AWP Update • Considering Diversity in Benefit Design & Communication

5. Pharmaceutical Coalition Primary Objective • Leverage the combined purchasing volume of a Coalition to change the way pharmaceutical products are purchased • create price transparent environment to encourage competition and consumerism • align incentives of PBMs with employers and patients • establish a platform for value-based purchasing • drive business to certified PBMs that agree with principles

6. Milestones • 2005 • Defined and identified transparency requirements for PBM certification • Skepticism to PBM reaction, viability of standards • Issued RFP to 31 PBMs in 2005 • Certified 3 PBMs – Aetna, MedImpact, and Walgreens Health Initiatives • 2006 • Added additional standards for certification • 10 PBMs certified/recertified • 2007-2008 • Streamlined Transparency Standards and documentation process • 13 PBMs certified/recertified, 1 previously certified PBM failed to meet standards

7. Current Certified Bidders • The 13 TIPPS-certified PBM vendors for 2008 are:

8. Update on Coalition Response • At least seven member companies transitioned to certified vendor arrangements, others may have moved without notifying Coalition • More pricing evaluations anticipated for Q2-Q4 2008 • High marketplace visibility has led to an increase in Coalition membership and interest

9. Overview of Transparency Standards • Format has been streamlined from nine requirements in 2006 to six requirements for current certification • Still designed to capture the ultimate in financial disclosure and service capability, and allow for a true partnership between a PBM and client • PBMs that outsource any core functionality must provide documentation of acceptance of the Transparency Standards from their outsourced partners

10. Transparency Standard 1 • Acquisition Cost for All Retail Claim Payments • Charge the employer no more than the amount that you pay the pharmacies in your retail network for each claim dispensed • Includes all brand and generic drugs

11. Transparency Standard 2 • Acquisition Cost Basis for All Mail Service Claim Payments • Charge no more than the acquisition cost of drugs at the mail order pharmacy, plus a dispensing fee • Acquisition cost is defined as either: • actual inventoried per unit cost (AAC), or • published Wholesale Acquisition Cost (WAC) • Agree to utilize a MAC list to determine the employer’s cost for any drugs that do not have an associated WAC price

12. Transparency Standard 3 • Pass-Through of 100% of All Pharmaceutical Manufacturer Revenue • Pass through 100% of any and all formulary rebates, market-share rebates, and other rebate revenue that the employer’s utilization enables you to earn • Includes Rebate Administrative Fees, Data Sale Revenue, and Compliance/Adherence program revenue

13. Transparency Standard 4 • Specialty Pharmacy Transparency • Charge no more than the acquisition cost of drugs at the specialty mail order pharmacy, plus a dispensing fee • Pass through any and all pharmaceutical manufacturer revenue • Provide dose optimization and consolidation programs, where appropriate • Provide case management for critical disease states (and not build cost of programs into ingredient cost) • Offer a tool to enable cross-walk billing (i.e., J-Code to NDC conversion)

14. Transparency Standard 5 • Plan Management/Consumer Engagement • Apply rebate on a per-unit basis specific to NDC-11 at the point of sale (at client’s discretion) • provide members with decision support tools: • web-based formulary lookup tool • web-based drug price comparison tool, with retail pharmacy pricing comparison • web-based or letter-based utilization summary tool that identifies member cost-share savings opportunities • Offer financial performance guarantees to support effective utilization management, by therapeutic class. • Penalties to be assessed on a dollar-for-dollar basis

15. Transparency Standard 6 • Comprehensive Audit & Disclosure Rights • Offer full audit rights • Audits of Claims/Utilization Data • Audits of Retail Network Contracts • Audits of Rebate Arrangements • Audits of Clinical Criteria • No limitation to specific list of audit firms • Allow self-audit by client • Provide claims data with all financial fields • Outsourcing vendors must also allow audits

16. Lessons Learned from Moving to Transparent Arrangements

17. Refining TIPPS Standards and Coalition Objectives

18. Evaluating Success? • Easing implementation of TIPPS contracts with certified PBMs • Increased number of employers moving to transparent agreements • Ensuring TIPPS equals savings • Broadening Coalition’s original objectives beyond transparency

19. Consensus • Maintaining Transparency Standards • Continue to make transparency a key objective • Powerful tool to help employers in negotiations • PBMs like public means of demonstrating commitment to transparency • Need to enhance savings opportunities • PBM interest in presenting TIPPS offers to new clients

20. Opportunities Going Forward • Incorporating pricing protocols into standards • setting a fair set of rules to understand pricing • Ex: new to market generics • MAC lists • Strengthening audit requirements • Standardizing TIPPS contracts/implementation tool • Manufacturer revenue • Specialty pharmacy • Creating new incentives for getting competitive pricing for TIPPS arrangements

21. Opportunities Going Forward • PBM fiduciary role • Acquisition cost at retail • Enhanced audit rights • Standard formulary development

22. TIPPS + Pricing Concept

23. Challenges with Current Certification Process • Employerswant idea of financial opportunity before conducting full TIPPS-based PBM RFP • Cost of PBM RFP process a deterrent for some • Certified PBMs not guaranteed chance to present their offer to member companies • Clients must still “select” the PBM for inclusion in a proposal process • PBMs may perceive diminishing returns for the cost of certification • Little incentive for PBMs to offer more competitive pricing for transparent arrangements

24. TIPPS + Pricing Concept • Supplemental fee for PBMs in addition to standard TIPPS certification • Additional fee revenue funds company-specific estimates • Cost estimated at approx. $5,000 per member company • Fee would depend on number of participating employers • Basic data collection needed for analysis • High-level information needed for each member company’s current arrangement and utilization patterns • 1-page data request form • PBM will NOT have access to data, Hewitt’s use of data limited to project

25. Current TIPPS Certification PBM offers TIPPS deals to member companies upon request (i.e. as part of a formal TIPPS-based proposal process) Member companies must fund the solicitation/evaluation of TIPPS proposals to determine savings opportunity TIPPS + Pricing Concept PBM receives all the benefits of standard TIPPS certification In addition, PBMs able to have pricing estimates presented to interested member companies via company-specific savings estimates Estimates to include side-by-side comparison of member company’s current deal vs. each TIPPS+ certified PBM deal Analysis results provided to all member companies free of charge TIPPS + Pricing Concept

26. TIPPS + Pricing Concept • Opportunities • Including pricing would generate fresh excitement about the Coalition among member companies, PBMs, media • Addresses employer need for savings as well as transparency without Coalition members paying additional fees • Creates incentives for PBMs to deliver competitive pricing and transparency • Ensures transparency remains top priority of Coalition • Provides participating PBMs greater exposure to employers

27. TIPPS + Pricing Concept • Considerations • Risk of marginalizing standard TIPPS certification • Requires commitment from a minimum number of companies to provide data in timely fashion at outset • PBM concerns • risk of alienating PBMs who do not opt in • higher fees could be a barrier for some • shifts focus of TIPPS from certification to typical “buying coalition” • estimates could set false expectations for clients • reluctance to offer best pricing without detailed claims data

28. Lunch

29. 2008 Calendar and 2009 TIPPS Process

30. Coalition Activity for 2008 • Coalition Newsletter • 3 editions for 2008: Spring (mid-April), Summer, and Winter • Focus on different topics, case studies from member companies • 2008 Target Dates • Week of April 28, follow up Coalition meeting/call • Week of May 12 PBM webcast/PBM forum on TIPPS process • Week of May 19, RFP release • July 14, Web conference for Coalition to review final RFP results • July 21, Final PBM certification decisions completed • Sep. 11, Washington Policy Conference, announce certified PBMs • Oct. TBA, Fall Coalition meeting

31. Consensus • Maintaining transparency standards • Continue to make transparency key objective • Powerful tool in educating the market • Enables PBMs to demonstrate commitment to transparency • Need to blend cost and transparency • Need to facilitate TIPPS implementation • PBM interest in greater exposure to new clients

32. Opportunities Going Forward • Strengthening TIPPS standards in 2009 RFP • Acquisition pricing • Updating MAC lists • Audit rights • Specialty pharmacy • Customized forumlaries • Request for feedback on development of standard formulary • Providing Coalition members tools to facilitate TIPPS implementation

33. Opportunities Going Forward (cont.) • Considering Pricing + Concept • Options for structuring Coalition meetings and interaction • Maximizing resources of PBMs in mutually beneficial manner

34. Managing Pharmacy for the Future

35. AWP Developments

36. AWP Settlement Update • Class action litigation in Massachusetts resulted in settlement with First Data Bank • Near term effects • settlement calls for one-time roll back adjustment • reduction in published AWP for commonly used drugs • PBMs likely to ask clients for adjustment • Long term effects • AWP could be phased out completely • No consensus reached on replacement strategy • “Fairness hearing” in January • Court failed to issue final ruling based on lingering concerns

37. Building the Bridge to the Next Generation of Diversity WorkAndrés TapiaChief Diversity Officer Hewitt Associates

38. For More Information… • HR Policy AssociationPharmaceutical Coalition Executive Director:Marisa MiltonMMilton@hrpolicy.org202-789-8671 • Hewitt’s TIPPS Project Manager:Joshua Goldenjoshua.golden@hewitt.com770-956-7777 • Hewitt’s TIPPS Vendor Manager:Vickie Loroncavickie.loronca@hewitt.com847-295-5000