UnitedHealth Pharmaceutical Solutions Specialty Pharmacy Program for your Oxford Plan

UnitedHealth Pharmaceutical Solutions Specialty Pharmacy Program for your Oxford Plan

Specialty medications require an approach that looks beyond the drug to the whole disease a comprehensive and integrated program to help promote evidence-based care at an affordable price.

UnitedHealth Pharmaceutical Solutions (UHPS) Specialty Pharmacy Program for your Oxford plan In the past several years, specialty medications have moved to the forefront of prescription drug management. Accounting for nearly 17% of pharmacy benefit spend, specialty drugs represent one of the most rapidly growing segments of health care. The use of specialty medications has grown significantly, with costs increasing nearly 20% annually, and there are more than 300 specialty medications in development, more than what is available on the market today. This explosive growth is due to several factors: The high rate of new medication introductions Expanded indications for existing medications Increased marketing to physicians and consumers The use of specialty medications as add-on therapies to be taken with current medications The individual s best interest Specialty medications are designed to address the most complex and life threatening diseases. They can enhance the productivity of life, and for some people, bring hope for life itself. When one is battling a life threatening disease, specialty medications are a life line making cost management a more sensitive and difficult issue. We understand both the opportunities and challenges that specialty medications present. In addition to their high cost, they require special handling, distribution, administration, and monitoring. Specialty medications require an approach that looks beyond the drug to the whole disease a comprehensive and integrated program to help promote evidencebased care at an affordable price. We define specialty medications broadly, having one or more of the following attributes: Unique distribution or administration (e.g., typically injectable or oral form) Market exclusivity to treat rare diseases (orphan drugs) Indication for chronic and life threatening diseases High cost (more than $250) Requires close monitoring by a pharmacist or physician

Here is how we do it. Simple solution: evidence-based decisions and support The Specialty Pharmacy Program promotes the right drug to the right person at the right place for an optimal cost and health outcome. Our Pharmacy & Therapeutics (P&T) Committee reviews published data to determine the clinical value of each specialty medication. Our Prescription Drug List (PDL) Management Committee, which includes representation from UnitedHealth Group s medical leadership, reviews the clinical recommendations of the P&T Committee, as well as pharmacoeconomic and economic evidence to determine the medication s overall value for placement on our prescription drug list. Our process promotes adherence to evidence-based best practices and consistency across pharmacy and medical management policies. This is the foundation on which our program was developed. Decisions are made with an understanding of the potential impact to medical care and costs. Specialty pharmacy network: maximizing patient support and cost Our specialty pharmacy network is uniquely designed to provide employees with convenient access to certain specialty medications at an affordable price. Our network currently includes select specialty pharmacies, each chosen based on clinical capabilities, quality of services and cost. In addition, we implement diseasespecific clinical criteria to identify opportunities for quality improvements. Specialty Pharmacy clinical programs To promote continuous quality improvement in our program, we have defined clinical criteria and corresponding management programs for several therapeutic categories including hepatitis C, growth hormone, multiple sclerosis, and rheumatoid arthritis. These programs will be linked to internal care management services. Decisions are made with an understanding of the potential impact to medical care and costs.

Superior service We have strict performance standards in place for our specialty network, so you can be confident your employees will receive superior service. Performance standards are in place for the following services: Medication storage and distribution Refill notifications Customer service (e.g., speed of answer, availability) 24 hour access to pharmacists Customer and member satisfaction ratings Member outreach and care management services Our specialty network pharmacies are held to high standards. Specialty Pharmacy Referral Line We realize that change can be difficult. To support your employees in transitioning to the new specialty network, the process starts with a simple phone call to the UHPS Specialty Pharmacy Referral Line. We understand that individuals may have just learned of a life-altering diagnosis and may be upset and confused. The referral line is staffed with professional customer service representatives who will explain the process and warm transfer the individual to a specialty pharmacy that specializes in his or her specific condition. Care management All of the pharmacies in the specialty network provide personalized care, monitoring and medication counseling. The dedicated and consistent service provided by the specialty pharmacies can have a direct impact on medication adherence and productivity. In addition to answering questions and coordinating medication delivery, a nurse will establish a plan tailored for the individual that may include educational materials and pharmacist counseling. If adherence is poor, or the individual is experiencing problems with the medication, a specialty pharmacy nurse will assess the issue and work with the individual to identify questions for his or her physician. Or, the nurse may contact the individual s physician directly. In addition to access to registered nurses, your employees have access to pharmacists 24 hours a day to answer any medication-related questions.

The UHPS Total Health Approach Specialty pharmaceuticals must be managed within the context of total health care. Our goal is to help manage the total condition, not just utilization of the specialty drug. Historically, and still today, many specialty medications were administered in physicians offices and reimbursed through the medical benefit. With a growing number of specialty medications that can be self-administered, about half of specialty medications are now distributed directly to the individual and reimbursed through the pharmacy benefit. So, in addition to our specialty network, we are working collaboratively with medical management to focus on some of the top volume and cost conditions. We are working with other UnitedHealth Group companies to help manage these diseases and their medication therapies regardless of the distribution or reimbursement channel. Nowhere is an integrated approach required more than with specialty medications. Our Specialty Pharmacy Program is comprehensive and addresses the following: Anemia Growth hormone deficiency Hemophilia Hepatitis C HIV/AIDS Infertility Multiple sclerosis Neutropenia Oral oncology Rheumatoid arthritis RSV prevention Pulmonary arterial hypertension Transplant Cystic Fibrosis Endocrine Enzyme Deficiency Hepatitis B Immune Modulator Iron Overload Osteoporosis Parkinson s Disease

Specialty pricing and reimbursement: a logical approach We take a thoughtful approach to specialty medication reimbursement. Simply carving specialty medications out of the medical plan can be disruptive to your employees and physicians. A logical approach is necessary to achieve the greatest financial value without disrupting care for your employees and negatively impacting physician relationships. There are times when reimbursing specialty medications through the pharmacy benefit is advantageous. For those medications that can be easily self-administered, such as those for growth hormone, we have implemented a program to move distribution to a specialty pharmacy and reimburse these medications through the pharmacy benefit. This poses little disruption to your employees and provides better pricing and reporting to you. We support and value the physician and patient relationship. We work with our physician network to establish appropriate reimbursement levels for professional services. And, we provide an evidence based approach that supports medication use in line with published clinical best practices, regardless of the distribution or reimbursement channel. For more information The UHPS specialty program is a comprehensive, total health solution to address the cost and care challenges of specialty medications. Our innovative, yet simple approach promotes quality, safe and effective coordination of care to your most treasured asset your employees. We look forward to working with you to manage the cost of specialty medications and promote superior coordination of care for your employees. For more information on the UHPS Specialty Pharmacy Program, contact your Oxford representative.

Oxford HMO products are underwritten by Oxford Health Plans (NY), Inc., Oxford Health Plans (NJ), Inc., and Oxford Health Plans (CT), Inc., and Oxford insurance products are underwritten by Oxford Health Insurance, Inc. MS-09-537 M46481 11/09 2009 United HealthCare Services, Inc.