How Specialty Pharmacies Can Use Data to Drive Revenue

The Trusted Source for Specialty Solutions
How Specialty Pharmacies can use
Data to Drive Revenue

The Trusted Source
for Specialty Solutions
Prepared by Therigy LLC | CONFIDENTIAL | Copyright © 2015 2
The Trusted Source for Specialty Solutions
Technology Suite
Therigy has built a proprietary
suite of technology products
for specialty pharmacies to deliver
best-in-class patient support.
Therigy’s experts provide hands-on
consulting services to assist clients in
planning and executing operational,
clinical and technology initiatives.
Therigy’s data analytics solutions
support the complex data capture
and unique reporting requirement in
the specialty space.

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Agenda
• Growth of Specialty
• Revenue Opportunities
• Business Requirements
• Key Success Factors
• Looking Ahead
• Questions

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Growth of Specialty

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Growth of Specialty
Prescription Drug Spend

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Growth of Specialty
$37,494,000,000
$47,769,000,000
$9,471,000,000
$28,721,000,000
2010 2014
Sales of Top 10 US Drugs: All vs. Specialty
All Drugs Specialty Drugs

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Growth of Specialty
$1,795
$5,670
2010 2014
Revenue per Patient of Top 10 Drugs by Year

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Growth of Specialty
Greater
Revenue
Fewer
Patients

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Business Requirements

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High cost
specialty
therapies
SPs need to
provide high
quality care
Need to demonstrate their performance to payers and manufacturers to succeed

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Traditional Specialty Pharmacy Services
Specialty Pharmacy Services
Referral Intake
Educational Materials Inventory of Specialty Products and
Ancillary Supplies
Reimbursement Support Clinical Intervention Services
Shipping and Ancillary Supplies at
no charge
Benefit Monitoring
Adherence/side effect
management
Inclusion of Ancillary Supplies:
Needles, Syringes, Alcohol Swabs,
Sharps
Prior Authorization Assistance
Safety Monitoring Temperature-controlled Shipping
and packing supplies
Access to Information on
Alternative Coverage Programs
Managing of Dose Changes Product and Administration
Training
Initial Clinical Assessment
Refill Reminder Phone
Calls/Delivery Coordination
Delivery directly to the Home,
Physician Office, or Other location
24-hour Availability with access to
Pharmacist or Nurse
Coordination of Home Training or
Infusions
Time Sensitive delivery

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Specialty
Pharmacy
Network
Decision
Ability of specialty pharmacy provider to:
• Engage patients effectively
• Collect clinical and patient feedback to
meet quality reporting requirements of
new payment and care delivery models
• Help patients and providers understand
the implications of specific medication
use throughout the care continuum
Ability of specialty pharmacy provider to:
• Reduce inappropriate utilization
• Ensure appropriate dose of medication
• Coordinate reimbursement and
eligibility
• Improve compliance and persistency
Manufacturer Considerations Payer Considerations
Specialty Pharmacies must support the unique contractual requirements of pharmaceutical manufacturers to
access Specialty Drugs and those of payers to secure reimbursement. Data is the key factor to both.

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*EMD Serono Specialty Digest™, 11th Edition
Specialty Pharmacy Reporting Services

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Advanced
Renal Cell
Carcinoma
(RCC)
Chronic
Myelogenous
Leukemia
(CML)
Chronic
lymphocytic
leukemia
(CLL)
Non-Small
Cell Lung
Cancer
(NSCLC)
Prostate Melanoma
Multiple
Myeloma
ExclusiveLimitedOpen
Limited to
Exclusive
Open to LimitedOpen to LimitedOpen to LimitedOpen to Limited

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Key Success Factors

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Key Success Factors
•Specialty Pharmacy Operating Model and SOPs
•Data Collection and Reporting Capabilities

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Key Success Factors
1
2Intake
1
Rx Entry
Benefits
Verification
Clinical
Assessment
Create
Order
Verify Rxs
(PV1)
Adjudicate
Claim
Pick Order
Verify Order
(PV2) Pack Order Ship Order
2 3 4
5 6 7 8
9 10 11
Referral
Process
Order
Process
Specialty Pharmacy – New Prescription Process Flow

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Monitoring and reporting of key operational and clinical metrics
1
2Intake
1
Rx Entry
Benefits
Verification
Clinical
Assessment
Create
Order
Verify Rxs
(PV1)
Adjudicate
Claim
Pick Order
Verify Order
2 3 4
5 6 7 8
9 10 11
Referral
Process
Order
Process
Time to therapy / Referral status

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1
2Intake
1
Rx Entry
Benefits
Verification
Clinical
Assessment
Create
Order
Verify Rxs
(PV1)
Adjudicate
Claim
Pick Order
Verify Order
2 3 4
5 6 7 8
9 10 11
Referral
Process
Order
Process
Prior authorization status / Benefits verification

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1
2Intake
1
Rx Entry
Benefits
Verification
Clinical
Assessment
Create
Order
Verify Rxs
(PV1)
Adjudicate
Claim
Pick Order
Verify Order
2 3 4
5 6 7 8
9 10 11
Referral
Process
Order
Process
Adherence / Medication Possession Ratio

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1
2Intake
1
Rx Entry
Benefits
Verification
Clinical
Assessment
Create
Order
Verify Rxs
(PV1)
Adjudicate
Claim
Pick Order
Verify Order
2 3 4
5 6 7 8
9 10 11
Referral
Process
Order
Process
Therapy performance standards

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1
2Intake
1
Rx Entry
Benefits
Verification
Clinical
Assessment
Create
Order
Verify Rxs
(PV1)
Adjudicate
Claim
Pick Order
Verify Order
2 3 4
5 6 7 8
9 10 11
Referral
Process
Order
Process
Dispensing accuracy / Daily shipments

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1
2Intake
1
Rx Entry
Benefits
Verification
Clinical
Assessment
Create
Order
Verify Rxs
(PV1)
Adjudicate
Claim
Pick Order
Verify Order
2 3 4
5 6 7 8
9 10 11
Referral
Process
Order
Process
Rxs requiring intervention / Non-dispensing errors

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Key Success Factors
•Monitoring and reporting of customer service / call center
performance:
–Customer service Speed of Answer
–Total blocked and abandoned calls
–Member prescription order resolution
–Member complaint resolution

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Monitoring and reporting of customer service / call center performance
Inbound call
volume vs.
abandonment
rate

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Looking Ahead

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Future Opportunities
• According to CMS, an ACO (Accountable Care Organization) is:
“an organization of health care providers that agrees to be
accountable for the quality , cost and overall care of Medicare
beneficiaries who are enrolled in the traditional fee-for-service
program who are assigned to it.”

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• The Centers for Medicare and Medicaid Services (CMS) have
implemented the Five Star Quality Rating System to help educate
consumers on quality of health care and make quality data more
transparent.
• The program rates health plans on multiple measures related to
medication management in the following areas:
–High-risk medications
–Diabetes treatment
–Medication adherence for diabetes
–Adherence for hypertension
–Adherence for cholesterol

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• High star ratings qualify health plans for federal bonus payments
and allow them to market their plans all year long.
• Higher star ratings translate into higher premiums. Health plans
can get quite a bit of money for having higher star ratings;
pharmacy benefits are an integral part of that formula.
• To increase their own rating, health plans can adjust their preferred
networks to include only better pharmacies that help contribute to their
higher rating.

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Dispense Accuracy / Payer Contract Penalties
Appendix A

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Appendix A
• Dispensing Accuracy Rate means (i) the number of all specialty
prescriptions dispensed by Pharmacy in each month with an incorrect drug,
strength, form, and directions for use, or a shipping-related error causing
medication to be delivered incorrectly, divided by (ii) the number of all
specialty prescriptions dispensed by Pharmacy in such month.
• Guarantee: 99.98% or greater specialty prescriptions filled with no
dispensing errors in each month (Payer book of business only
measurement).
• Penalty: $20,000 for each full 0.01% shortfall in accuracy/per month with
maximum per year penalty of $150,000.

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Appendix A
71%
3%
3%
8%
9%
6%
Medication Errors – 2014Q4
Wrong Quantity (n=25)
Wrong Medication (n=1)
Wrong Sig (n=1)
Wrong Patient (n=3)
Wrong Form (n=3)
Wrong Strength (n=2)
Total Errors = 35

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Appendix A
99.60% 99.65% 99.70% 99.75% 99.80% 99.85% 99.90% 99.95% 100.00%
K1
J0
I9
H8
G7
F6
E5
D4
C3
B2
A1
99.76%
99.93%
100.00%
100.00%
99.94%
100.00%
99.92%
99.88%
100.00%
100.00%
99.93%
99.88%
100.00%
99.98%
99.98%
99.94%
99.94%
99.99%
100.00%
99.96%
99.93%
99.98%
99.97%
99.98%
99.97%
99.96%
99.91%
99.99%
99.95%
100.00%
99.97%
100.00%
99.94%
2014Q4
2014Q3
2014Q2
99.98%

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Pharmaceutical Manufacturer Reports
Appendix B

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Appendix B
Required (Y/N) # Data Class Column Name NCPDP Name/# Data Type Length Column Description
Y SDI required field Record Code Identifier Text 4
Record indicator for Patient information.
Must contain the value PAT
Used by SDI Encryption process.
Y SDI required field Patient Last Name
Patient Last Name
(311-CB)
Alphanumeric 80 Used by SDI Encryption process.
Y SDI required field Patient First Name
Patient First Name
(311-CA)
Alphanumeric 80 Used by SDI Encryption process.
Y SDI required field Patient Address
Patient Street Address
(322-CM)
Alphanumeric 80
Street Address (No city, state)
Y SDI required field Patient Zip Code
Patient Zip/Postal Code
(325-CP)
Numeric 5
5 digit ZIP
Used by SDI Encryption process
Y SDI required field Date of Birth
Date of Birth
(304-C4)
Numeric 8
Patient Date of Birth
Must be in YYYYMMDD format
Y SDI required field Gender
Patient Gender Code
(305-C5)
Numeric 1
Code identifying gender
1 for Male,
2 for Female,
0 for Unknown or Not Specified.
Y SDI required field Filler Alphanumeric 1
For future use and
Leave Blank
Y 1 Record ID N/A Numeric 10
Unique ID for each record. This record ID should be
persistent across all VENDOR data feeds.
Y 2 Record ID Record Action Type Code N/A Text 20
Possible values:
INSERT= this record is a new record
UPDATE= this record is a restatement of a previously sent
record with the same Record ID
DELETE= all previously sent records with the same Record
ID as this record should be deleted

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Appendix B
Required (Y/N) # Data Class Column Name NCPDP Name/# Data Type Length Column Description
Y 82 Patient Patient status N/A Text 20 PENDING – A referral has been received but product has
not yet been shipped to the patient.
DENIED – A referral has been received but the SPP will
not provide service. The patient did not
receive any shipment.
DISCONTINUED – The patient has received at least one
shipment from the SPP but will no
longer be serviced by the SPP.
SHIPPED – The patient has received shipment from the
SPP and is actively receiving product.
Y 83 Patient Patient status reason code N/A Alphanumeric 20 Detailed patient status reason codes
PENDING Reasons:
P01: New referral
P02: Pending benefits investigation
P03: Pending prior authorization
P04: Order cleared, ready to ship
P05: Pending patient decision
P06: Pending physician decision
P07: Unable to contact patient
P08: Other
P09: Pending clinical reason
P10: Pending for inventory
P11: Pending re-authorization
P12: Delay in treatment initiation
DENIED Reasons:
DN01: Patient’s choice, product not covered by
insurance plan
DN02: Patient’s choice, co-pay too high
DN03: Patient’s choice, other

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URAC Accreditation Measures
Appendix C

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Appendix C

How Specialty Pharmacies Can Use Data to Drive Revenue

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