WHEN IT COMES TO CANCER, NO ONE CAN AFFORD TO WASTE OPPORTUNITIES INTRODUCING ADVANCED ONCOLOGY SOLUTIONS

BR39555K_AOS_BR_Layout 1 4/19/10 4:22 PM Page 2 WHEN IT COMES TO CANCER, NO ONE CAN AFFORD TO WASTE OPPORTUNITIES INTRODUCING ADVANCED ONCOLOGY SOLUT...
Author: Homer Foster
0 downloads 0 Views 2MB Size
BR39555K_AOS_BR_Layout 1 4/19/10 4:22 PM Page 2

WHEN IT COMES TO CANCER, NO ONE CAN AFFORD TO WASTE OPPORTUNITIES INTRODUCING ADVANCED ONCOLOGY SOLUTIONS

BR39555K_AOS_BR_Layout 1 4/19/10 4:22 PM Page 3

NOW YOU HAVE AN OPPORTUNITY TO: INCREASE MEDICATION ADHERENCE PERSONALIZE DRUG THERAPIES BETTER MANAGE DRUG SPEND

HELP PATIENTS LIVE BETTER LIVES

BR39555K_AOS_BR_Layout 1 4/19/10 4:22 PM Page 4

LET ADVANCED ONCOLOGY SOLUTIONS HELP YOU IMPROVE OUTCOMES AND CONTROL COSTS For every 1,000 people in your plan, an average of five could be diagnosed with cancer this year.1 Are you sure they will have the best chance of a good outcome? Are you confident that your dollars

10.8M Americans are living with or have had cancer.2

will be spent to the greatest effect? Who will work to make sure that clinical services are aligned with evidence-based practices? Advanced Oncology Solutions. Powered by America’s most advanced pharmacy, the Advanced Oncology Solutions program can help improve financial and clinical outcomes for plan sponsors and patients. By combining the efficiencies and service innovations of Medco with the high-touch care model of Accredo, we work to identify and close those gaps in care that can waste resources and lead to inconsistent treatment.

BETTER RESULTS FOR PLAN SPONSORS, PHYSICIANS, AND PATIENTS By carving out the management of your oral oncology spending with us, you have the potential to see better outcomes across the board. Plan sponsors gain a team of oncology professionals with expertise in cancer medications to help obtain greater visibility into cancer spending for more effective care and coverage decisions. Physicians gain the support of pharmacists who can bring underutilized genetic tests to their attention, help improve patient adherence levels, and help make patient care every bit as targeted as the new cancer drugs being prescribed. These pharmacists also support physicians’ efforts to make the safest, evidence-based care decisions. Patients gain a better chance at an improved quality of life while they are under treatment. They have the support of a caring team with experience in cancer drug therapies who understand what they are going through and know how to help.

Ask your account representative how Advanced Oncology Solutions could benefit your plan and patients today.

1.

Surveillance, Epidemiology, and End Results Program, Delay-adjusted Incidence database: SEER Incidence Delay-adjusted Rates, 9 Registries, 1975-2005, National Cancer Institute, 2008. 2, 3. United States Department of Health and Human Services, Agency for Healthcare Research and Quality. Available at http://www.ahrq.gov/qual/nhqr07/Chap2.htm#cancer. Accessed March, 2010.

$78.2B was spent on oncology healthcare in 2006.3

BR39555K_AOS_BR_Layout 1 4/19/10 4:22 PM Page 5

THE DIFFERENCE BEGINS WITH OUR ONCOLOGY THERAPEUTIC RESOURCE CENTER PRACTICING AMERICA’S MOST ADVANCED ONCOLOGY PHARMACY CARE At the center of Advanced Oncology Solutions is our new, state-of-the-art Oncology Therapeutic Resource Center (TRC), staffed by a team of pharmacists with expertise in cancer medications. Supported by the industry’s most innovative technologies and processes, these pharmacists help to enhance the safety and efficacy of each patient’s complete drug regimen, including specialty and traditional anticancer therapies; targeted therapies, biologics, and hormonal treatments; injectable, infused, and orally administered medications; growth factors, antiemetics, and other drugs used to mitigate the symptoms of cancer and its treatment.

CONCENTRATING EXPERTISE IN CANCER SUB-TEAMS Trained in the specific medication-related needs of their patients, many of our pharmacists are organized into sub-teams around a major cancer or patient type. These teams are already in place to support patients across the three cancer types that are most commonly treated with oral and injectable medications: breast, prostate, and hematologic. The pharmacists focus their efforts on measures that have the potential to decrease complications and hospitalizations, including:

There are more than

200 different types of cancer.4

Over

40% of the R&D pipeline is dedicated to oncology drugs.5

Who has the resources to keep up with this complexity?

We do.

> Coordination of drug regimens > Protocol oversight > Safety > Patient adherence > Chemotherapy side effect management > Nutritional counseling They also work closely with our customer service representatives to keep patients informed and engaged with their drug therapies. We are in the process of creating sub-teams to help patients with cancers that are typically treated with infused medications, including colorectal, lung, and gynecologic malignancies.

How to direct more patients to the Oncology TRC:

SYNCHING ORAL MEDICATIONS WITH INFUSED THERAPIES

> Limit your specialty pharmacy network.

For patients who receive infused medications at community hospitals, academic medical centers, and other inpatient settings, we contact physicians to schedule home delivery of oral medications so that they coincide with the patient infusion schedules. This way, our pharmacists can further protect patients by performing drug utilization review on their entire therapy regimen.

4. National Cancer Institute. Available at http://www.cancer.gov/cancertopics/alphalist. Accessed 11//19/09. 5. Oncology Business Review, IMS Health, November 2007

> Build incentives into your benefit design.

> Implement medical channel management for anemia drugs.

BR39555K_AOS_BR_Layout 1 4/19/10 4:22 PM Page 6

COORDINATING PATIENT-CENTRIC SERVICES ACROSS THE CONTINUUM OF CARE Today, the Oncology TRC offers services that close gaps in care, increase visibility of cancer spend, and share evidence-based practices with plan sponsors, physicians, and patients. In the near future, we expect the TRC to become the hub of seamlessly connected services that touch patients at nearly every stage across the continuum of cancer care. Provides a range of services needed to take advantage of advanced genetic testing, including diagnostic, prognostic, and response monitoring.

Offers the clinical insight needed to create customized coverage rules, channel management guidelines, and tailored programs that meet your BENEFIT plan objectives.

PERSONALIZED MEDICINE

CONDITION MANAGEMENT

DESIGN

SCREENING & WELLNESS

ONCOLOGY THERAPEUTIC RESOURCE CENTER

Supports the complex needs of cancer patients with services including RationalMed®, Optimal Health® disease management, and Extended Enterprise Services to improve the coordination of care delivery.

ONGOING SUPPORT

COMING SOON In addition to offering online resources for patients, our ultimate aim is to connect services, transitioning seamlessly from active treatment to the next phase, regardless of the clinical outcome.

COMING SOON Ultimately we expect to offer access to a variety of wellness, health education, and screening programs.

Our pharmacists work to improve adherence and promote the safe and effective use of medications through: > Cancer Sub-Teams Patients are routed to the cancer sub-team that is trained in the medications used in treating their specific condition. > Drug Utilization Review Every oncology prescription—specialty or traditional, filled at retail or mail— is screened for numerous safety considerations and also flagged if relevant pharmacogenomic testing has been skipped. > Enhanced Services • Nutritional counseling • Protocol adherence programs

BR39555K_AOS_BR_Layout 1 4/19/10 4:22 PM Page 7

HELPING YOU MANAGE ONCOLOGY SPEND MORE EFFECTIVELY The expenses associated with cancer treatments are notoriously complex and difficult to manage.

Estimated oncology drug sales 6 80

$80

70

Today, new drugs are entering the market at a

Billion

60

faster rate than ever. Cost trends keep escalating, 50

yet these drugs come with no guarantees of efficacy. 40

It can be hard to determine which new therapies substantially improve quality of life and survivability and how to integrate them into benefit design. It can be equally difficult to keep patients adherent with appropriate therapies and to handle the increased cost of cancer recurrences and hospitalization when they don’t adhere.

$48 Billion

30 20 10 0

2008

Advanced Oncology Solutions can provide cohesion and visibility across many of the interconnected elements of oncology care. We work to improve outcomes and control spending by supporting the safe and appropriate use of expensive and high-risk medications, including measures to optimize adherence.

ADVANCED REPORTING AND ANALYSIS Comprehensive reporting and analytic capabilities provide you with the ability to monitor pharmacy spending and understand its impact on total healthcare costs, particularly when integrated with the RationalMed patient safety program from Medco: > Report Manager—Delivers integrated oncology reporting > Expert Advisor—Provides oncology-specific capabilities > Client Value Report—Details gap closure and TRC metrics

Gain the care and cost advantages of Advanced Oncology Solutions today > Direct patients to the Oncology TRC by implementing benefit design changes, specialty pharmacy network limitations, and medical channel management programs. > Enroll in Medco’s oncology coverage rules. > Utilize services that reduce hospitalization, such as RationalMed and personalized medicine, plus symptom and nutrition counseling.

6. IMS Health. May 2008. 7. American Cancer Society. Compares periods 1975-1977 vs. 1996 -2002.

2012

BR39555K_AOS_BR_Layout 1 4/19/10 4:22 PM Page 1

Only organizations on the scale of Medco and Accredo could have the volume of cases needed to cost-effectively offer the specialized care practiced by Advanced Oncology Solutions.

Talk to your benefits consultant or account/sales representative today, and let us create a customized solution that’s right for your organization.

Medco, medco.com, RationalMed, and Optimal Health are registered trademarks and the Advanced Oncology Solutions logo is a trademark of Medco Health Solutions, Inc. Accredo and the Accredo logo are registered trademarks of Accredo Health Group, Inc., a wholly owned subsidiary of Medco Health Solutions, Inc. © 2010 Medco Health Solutions, Inc. All rights reserved. BR39555K

Introducing the new Medco Therapeutic Resource Center® for oncology patients THE WORLD’S MOST ADVANCED ONCOLOGY PHARMACY The new Medco Therapeutic Resource Center (TRC) represents a major advance in efforts to provide safe, effective, and affordable pharmacy care to cancer patients. Headquartered in Whitestown, Indiana, the new Oncology TRC offers the services of specialist pharmacists and dedicated support personnel who will manage more than 930,000 patients currently living with cancer. PUTTING PHARMACISTS FRONT AND CENTER The TRC provides an ideal environment for oncology pharmacists to actively participate in the care of cancer patients. They will identify treatment

gaps and address quality-of-life issues, such as managing drug side effects. The TRC places pharmacists in a more central role in improving health outcomes for patients with common forms of cancer, such as breast and prostate cancers, patients with benign and malignant hematologic conditions, and special needs populations, such as children with cancer. THOROUGH OVERSIGHT OF CANCER THERAPY REGIMENS The TRC combines oncology clinical expertise from its specialty pharmacy, Accredo Health Group, and its TRC in Willingboro, NJ. Specialist pharmacists

will be organized into teams focused on specific tumor treatments. Consolidating both traditional and specialty pharmacy oncology medications, they will review anti-cancer regimens that include oral cancer medications and supportive therapies, such as anti-nausea treatments. Specialist pharmacists will oversee the patients' drug therapies completely, providing attention to medication safety and other conditions besides cancer.

THE NEW ONCOLOGY TRC: > Covers 20,000 sq. ft. > Places specialist pharmacists in a central role for improving health outcomes > Will manage the medication needs of over 930,000 patients

Over, please

ADVANCING OUR COMMITMENT TO CANCER PATIENTS The new Oncology TRC marks a major expansion of Medco’s commitment to advance cancer care with personalized and specialized treatment for oncology patients. Each day our pharmacists can supplement care in the areas of promoting medication adherence, identifying appropriate genomic tests for targeted therapies, and consulting on evidence-based care decisions. SEE HOW THE ONCOLOGY TRC COULD HELP IMPROVE OUTCOMES FOR PATIENTS AND PLANS For more information about the new Oncology TRC, or the extraordinary Advanced Oncology Solutions capabilities it supports, contact your consultant or Medco or Accredo account/sales representative today.

ACTIVELY SUPPORTING ONCOLOGY RESEARCH In addition to providing advanced pharmacy care to oncology patients, the Oncology TRC will play a pivotal role in Medco’s oncology research initiatives. Medco has been actively engaged in three studies over the past year: 1 l Breast cancer Certain antidepressants impair the metabolism of the breast cancer drug tamoxifen, making it less effective. Patients using tamoxifen with antidepressants, such as Prozac® (fluoxetine), Paxil® (paroxetine), and Zoloft® (sertraline), had a 1.9-fold higher risk of recurrence than patients using antidepressants that are weak inhibitors of the liver enzyme CYP2D6.1 The weak inhibitors of the enzyme include Celexa® (citalopram), Lexapro® (escitalopram), and Luvox® (fluvoxamine).

1. Aubert RE, Stanek E, et al. Risk of breast cancer recurrence in women initiating tamoxifen with CYP2D6 inhibitors. Journal of Clinical Oncology. 2009; 27(suppl):S18 Abstract CRA508. 2. Lust S, Subar M, et al. A retrospective review of erythropoiesis stimulating agents (ESA) usage in pharmacy claims data. Blood (ASH Annual Meeting Abstracts), Nov 2009; 114:900. 3. Stanek E, Aubert RE, et al. Inadequate BCR-ABL monitoring in imatinib-treated patients with chronic myelogenous leukemia. Journal of Clinical Oncology. 2009; 27(suppl):S15. Abstract 7077. All rights in the product names of all third-party products appearing in this document, whether or not appearing with the trademark symbol, belong exclusively to their respective owners. Medco and Medco Therapeutic Resource Center are registered trademarks of Medco Health Solutions, Inc. Accredo and the Accredo logo are registered trademarks of Accredo Health Group, Inc., a wholly owned subsidiary of Medco Health Solutions, Inc. © 2010 Medco Health Solutions, Inc. IN40017I

2 l Anemia Evidence indicates that physicians have adjusted prescribing habits after the FDA published alerts and inserted boxed warnings into product labels for erythropoiesis stimulating agents (ESAs) in 2007. This resulted in a reduction in the spend for these agents, which were prescribed for cancer-related anemia.2 Additional studies are planned to determine if this decrease led to any change in ER visits or hospitalizations for this group of patients. 3 l Chronic myeloid leukemia Assessment of patients with chronic myeloid leukemia should include testing for the BCR-ABL gene and its product. Physicians are not conducting necessary follow-up gene testing for Gleevec® (imatinib) patients to determine whether the treatment is working. Only 14 percent of patients had the BCR-ABL gene measured for consecutive quarters. Only 60 percent had evidence of having one gene test performed at any period over 1.5 years.3

Coverage Rules TAKING THE GUESSWORK OUT OF ONCOLOGY COVERAGE RULES Our coverage rules are based on the latest clinical research and help promote the safe, effective use of oncology drugs through your plan benefit. Two packages are available: one offering drug selection rules only, the other adding quantity management rules.

BENEFITS: • Maximize safety and effectiveness > Promote the use of safe, appropriate medications for each condition > Reduce exposure to treatments for which effectiveness is not known • Minimize off-label use and reduce cost > Apply evidence-based guidelines to each indication > Provide effective adjudication of FDA label and compendia > Reduce exposure to cost associated with uses that are unproven • Ease of administration > Automatic updates for new drug introductions, black box warnings, and new indications > No changes to pricing or documents for new drugs

The proper oversight of oncology drug utilization involves a thorough review of ongoing pharmaceutical research. Each day new research can highlight new indications for drugs, or even new warnings. Advanced Oncology Solutions takes the guesswork out of the process by assembling coverage rules that are easy to implement within your benefit. Automatically updated whenever new research triggers drug labeling or compendia changes, these rules promote using the right drugs to treat patients to help avoid complications.

2010 oncology coverage rules apply to the following commonly prescribed oncology drugs: Afinitor®*

Revlimid®*

Thalomid®

Avastin®*

Sprycel®*

Torisel®

Dacogen®

Sutent®*

Tykerb®*

Erbitux®*

Tarceva®*

Vectibix®

Gleevec®*

Tasigna®*

Vidaza®*

Nexavar®*

Temodar®

Zolinza®*

*Includes quantity duration rules within package 2.

CHOOSE THE SOLUTION THAT BEST MEETS YOUR PLAN NEEDS Our packaged solutions include over 30 FDA label, compendia-based coverage rules, all of which are automatically updated with new agents. Package 1: Drug selection rules only Designed for plans that require pre-authorization. Promotes adherence to plan benefit and protects patient safety through clinically appropriate drug use, including constraints on off-label or off-compendia use. Package 2: Drug selection and quantity management rules Supports dosing accuracy in accordance with your plan benefit by adding quantity-related rules to the pre-authorization rules in Package 1. Also includes quantity duration rules for certain medications (those drugs marked with an asterisk in the table above).

FIND OUT MORE ABOUT ONCOLOGY BENEFIT MANAGEMENT To learn more about how oncology coverage rules packages can help protect your patients and your plan, contact your consultant or Medco or Accredo account/sales representative today.

All rights in the product names of all third-party products appearing in this document, whether or not appearing with the trademark symbol, belong exclusively to their respective owners. Medco is a registered trademark of Medco Health Solutions, Inc. Accredo and the Accredo logo are registered trademarks of Accredo Health Group, Inc., a wholly owned subsidiary of Medco Health Solutions, Inc. © 2010 Medco Health Solutions, Inc. IN40016O

Pharmacy Network Management Program PHARMACY NETWORK MANAGEMENT DRIVES IMPROVED ADHERENCE AND BETTER CLINICAL OUTCOMES After reaching a preset number of refills (typically two) for appropriate oncology medications, patients switch to pharmacy service by mail and gain the full advantages of our Oncology Therapeutic Resource Center for ongoing management.

BENEFITS: • Oversight of pharmacy regimen for enhanced safety • Improved coordination of care • Consistent application of clinical protocols • Encourages patient adherence • Potential for cost savings

A typical cancer patient requires an average of ten oral prescription medications, creating a significant need for pharmacy oversight. The ability to monitor adherence and synchronize dispensing with provider-infused therapy regimens is critical to this patient population. Yet a retail pharmacy is simply not equipped to manage the complexities associated with co-morbidities and multiple medications. The solution is Pharmacy Network Management (PNM), which enables the needs of cancer patients to be better served through a cohesive care model such as our Oncology Therapeutic Resource Center (TRC). By limiting the number of prescription fills a patient can receive at retail, we can deliver oncology pharmacy care that helps to enhance patient adherence to their medications, potentially lowering costs for patients and plan sponsors.

IMPROVED COORDINATION OF CARE Specialist pharmacists in the Oncology TRC are central to the coordination process, identifying and closing gaps in care that can lead to wastage and poor outcomes. Practicing within America’s most advanced oncology pharmacy, they are ideally positioned to manage drug utilization review, to help patients avoid potential drug interactions, and to promote adherence to essential medications. Supported by real-time IT-driven alerts, our pharmacists have a more complete oversight of all oral prescription medications and can coordinate dispensing with infused chemotherapies.

PROVEN THERAPY MANAGEMENT PROTOCOLS 1 A common misconception is that oral oncology drugs are less toxic than infused therapies. In fact, oral cancer medications can pose additional risks because they require self-administration by a patient or caregiver. Specially trained pharmacists can help mitigate these risks by counseling patients on drug administration and side effects, and by avoiding dispensing errors that can lead to hospitalization and poor treatment outcomes. Our pharmacists follow a detailed dispensing protocol unique to our Oncology TRC that is designed to optimize drug adherence, minimize wastage, and improve outcomes. These protocols have been shown to improve adherence levels compared with the retail pharmacy setting,1 potentially leading to better patient outcomes and lower healthcare costs.

Over, please

MORE PERSONALIZED PATIENT BENEFITS Our specialist pharmacists provide more than dispensing oversight. Using an integrated IT platform, they identify both clinical and financial opportunities for patients to improve their healthcare and lower out-of-pocket costs. Advanced Oncology Solutions also incorporates industry-leading personalized medicine innovations into the practice of pharmacy. Foundational genomic tests are built into drug utilization review, therapy protocols, and coverage authorization rules to enhance patient safety and reduce costs.

PHARMACY NETWORK MANAGEMENT IS EASY TO IMPLEMENT Simply select a retail-fill frequency limit, and we’ll direct patients to use our mail service for appropriate medications. That way, they will be able to take full advantage of our Oncology TRC and everything Advanced Oncology Solutions has to offer. To learn more about how we can help you improve patient adherence and coordination of care, contact your consultant or Medco or Accredo account/sales representative today.

1. On-demand peer group Book of Business report. Reporting period: July 1, 2009-December 31, 2009. 2. Accredo Oncology Pipeline, Promising Phase 2 and Higher. Data extracted November 10, 2009. Medco is a registered trademark of Medco Health Solutions, Inc. Accredo and the Accredo logo are registered trademarks of Accredo Health Group, Inc., a wholly owned subsidiary of Medco Health Solutions, Inc. © 2010 Medco Health Solutions, Inc. IN40018M

Between now and 2013, as many as

32 new oral oncology chemical entities may be approved by the FDA.2

Medical Channel Management Program MEDICAL CHANNEL MANAGEMENT SUPPORTS GREATER CONSISTENCY AND COST CONTROL

In many cases, oncology drugs can be better managed for clinical appropriateness and cost control through a specially constructed pharmacy benefit versus a medical benefit.

BENEFITS: • Greater oversight of utilization and cost • Consistently applied clinical protocols for use and dosing • More detailed reporting and diagnostics

Many plan sponsors unwittingly pay for a significant proportion of their specialty pharmacy spend, including oncology drugs, via the medical benefit. These claims are not subject to the checks and balances associated with an effective pharmacy benefit manager, and as a result, they can often lead to higher overall costs and inappropriate clinical use. The Medical Channel Management (MCM) program helps plan sponsors gain better and more consistent oversight of these situations. With MCM, certain clinically appropriate specialty drugs are excluded from the medical benefit and are instead adjudicated via the pharmacy benefit. Patients receive their drugs directly from Advanced Oncology Solutions, where pharmacists with expertise in cancer medications work to protect patients through the consistent application of clinical protocols.

REDUCE INEFFICIENT SPENDING As much as 30-70% of specialty drug spend is currently billed under a J-codebased medical benefit 1, where visibility is poor and active management is difficult. In fact, nearly 20% of drug claims billed under the medical benefit use a “Miscellaneous” code2. In the absence of an effective MCM strategy, many plan sponsors lack program controls and suffer from deficiencies that may include: • Lack of cohesive drug health and safety oversight/coordination • Limited reporting and utilization management • Inappropriate off-label use or incorrect dosing • Medical benefit “leakage” in response to retail pharmacy management programs

GAIN VISIBILITY, EFFICIENCY AND SAFETY Benefit design tools provided by Medical Channel Management allow patients and plan sponsors to gain tighter controls and enhanced patient safety measures. With just a one-time program change, MCM can result in both clinical and financial dividends for years to come as more specialty drugs come onto the market. Our capabilities include specific real-time adjudication for each NDC drug code, enabling your program to expand dynamically once it has been established.

TWO FULLY CUSTOMIZABLE OPTIONS TO MEET YOUR PLAN GOALS 1. Self-administered therapies which are designed for administration by an individual or caregiver in a private setting. 2. Clinician-administered therapies which are administered by a trained professional in a private setting, infusion center, or doctor’s office, as permitted by law. Patients can be matched to an appropriate location. Over, please

THE RIGHT PROGRAM FOR ANEMIA AND ORAL ONCOLOGY Certain anemia and oral oncology therapies, often administered under the medical benefit, are excellent candidates for the self-administered program. Anemia Aranesp® and Procrit® are drugs used to treat anemia, often in conjunction with oncology regimens. These drugs can be packaged so that the drug can be administered in the home by the patient or caregiver with minimal disruption to the patient’s schedule or lifestyle. Patients receive counseling by a pharmacist and therapy follow-ups. They can access assistance by phone from a trained professional whenever the need arises. Through a combination of therapy and coverage management, Advanced Oncology Solutions has demonstrated that savings can be achieved through a self-administered program for anemia drugs. Therapy management includes: • Nationally accepted clinical and practice guidelines • Patient training and counseling • Adherence monitoring • Waste management • Side effect management • Vial optimization • Health and safety protocols Coverage management supports drug-level coverage that is consistent with plan design intent and accepted clinical guidelines. It provides appropriateness of coverage for specific drugs or amounts of drugs and includes: • Product selection (prior authorizations, step therapy) • Quantity management (dosage, overuse, and waste) • Integrated, real-time DUR edits Oral oncology Although oral oncology drugs are typically managed under your pharmacy benefit, some oral oncology drugs may be administered under the medical benefit. With oral medications representing more than 25% of the oncology drug pipeline, establishing your MCM program today assures pharmacy oversight of existing and future self-administered products.

PUT MEDICAL CHANNEL MANAGEMENT TO WORK To learn more about how MCM can help you reduce the cost of your specialty drug coverage while helping patients manage critical aspects of their therapy, contact your consultant or Medco or Accredo account/sales representative today.

1. Flushman, Howard. The End of Buy-and-Bill? The RPM Report. September 2006; Vol. 1, No. 9. page 25. 2. Medco book of business analysis, 2009. Accredo Medical Conversion Report for six clients using MCM, January-June 2009. 3. Drug spending for 367 patients measured for 6 months on medical benefit (pre-conversion) Aranesp is a registered trademark of Amgen, Inc. Procrit is a registered trademark of Johnson & Johnson. Medco is a registered trademark of Medco Health Solutions, Inc. Accredo and the Accredo logo are registered trademarks of Accredo Health Group, Inc., a wholly owned subsidiary of Medco Health Solutions, Inc. © 2010 Medco Health Solutions, Inc. IN40016Y

In an Accredo study, clients using MCM reduced costs by nearly $1 million for a

19% savings

3

Personalized Medicine for Oncology MORE PRECISE MEDICATION THERAPY SELECTION PROMOTES BETTER OUTCOMES

Advanced Oncology Solutions offers leading personalized medicine capabilities that help deliver enhanced care and safety for members while potentially lowering healthcare costs for plans. We use the latest advances in genetic testing to trigger patient and physician alerts, prompt cost-saving coverage rules, and provide physicians with test results that they can use to make more precise prescribing decisions.

BENEFITS: • Works to mitigate waste, as patients obtain the right drug therapy more quickly • Helps to avoid “trial and error” prescribing decisions • Increases the opportunity for a given therapy to improve health outcomes • Reduces the chance for harmful side effects and the resulting need for urgent care • May lower overall healthcare costs due to potentially fewer hospitalizations and adverse outcomes

Advanced Oncology Solutions leverages Medco’s innovative ability to monitor the latest personalized medicine opportunities, including pharmacogenomic testing, and incorporates them into coverage rules and genetic drug utilization review (DUR) alerts that drive enhanced safety and cost control. We can also support physicians in making treatment decisions that are more specific to individual genetic variations and cancer-related mutations. There are several types of tests related to oncology, including: • Screening—profiles individual cancer risk • Diagnostic—establishes the presence of a specific disease or cancer type • Therapy management—informs treatment decisions once a diagnosis has been established. The purpose of the test can be: > Prognostic—assesses tumor risk and subclassifies disease by molecular subtype > Predictive—indicates likelihood that a treatment may be effective based on: 1. Patient characteristics—e.g., assessing CYP2D6 genetic type that can limit the efficacy of tamoxifen, a drug commonly used to prevent and treat breast cancer 2. Tumor characteristics—e.g., HER2 expression as predictive testing for the breast cancer drug Herceptin® > Response monitoring—tracks response to treatment and may guide future therapy (e.g., measuring BCR-ABL levels in chronic myeloid leukemia patients)

HOW IT WORKS TO DELIVER REAL RESULTS FOR PATIENTS Through our new, state-of-the-art Oncology Therapeutic Resource Center, we integrate automated alert systems directly into the pharmacist’s daily workflow to deliver enhanced pharmacy services for physicians and patients. Examples include: • Alerting pharmacists to a patient’s simultaneous use of tamoxifen with certain medications that mimic the genetic poor-metabolizer phenotype and inhibit the efficacy of tamoxifen • Providing oversight of targeted therapies that have associated biomarkers for which testing of tumor tissue is recommended or required, including: > Alerting pharmacists to HER2 testing for patients who are prescribed drugs such as Tykerb® or Herceptin® > Alerting pharmacists to KRAS testing for patients who are prescribed drugs such as Erbitux® or Vectibix® that are not effective in patients with KRAS mutations Over, please

We can also offer selected testing for cancer patients on an a-la-carte basis, coordinating contact with the physician, patient, and laboratory. Clinical analysis is led by Advanced Oncology Solutions (AOS) specialist pharmacists who have expertise in the medications used to treat cancer. Here’s the typical flow for the CYP2D6 genetic test for tamoxifen:

Poor metabolizers of tamoxifen have a

1. Patient is identified via real-time prescription data 2. Physician is engaged to gain permission for test 3. Patient is contacted to educate and gain consent 4. Patient receives self-test kit and returns cheek swab sample to lab 5. Specialist pharmacist and physician receive results

7. Patient’s drug regimen is modified, as necessary

Personalized medicine in action Physician

Advanced Oncology Solutions

Inform, educate, and gain permission for the appropriate test

Patient

Results analysis

After pharmacist consultation with physician, patient’s drug regimen may be modified

RIGHT TEST, RIGHT DRUG, RIGHT NOW The opportunity to realize the benefits of personalized medicine is here. Advanced Oncology Solutions gives clients access to the care and cost advantages of today’s genetic testing and will continue to introduce new tests and alerts in the future as they are developed. To learn more about how our personalized medicine capabilities can help enhance the safety and effectiveness of your members’ drug therapy, while helping to mitigate waste and reduce healthcare costs, contact your consultant or Medco or Accredo account/sales representative today.

1. Goetz MP, Knox SK, Suman VJ, et al. The impact of cytochrome P450 2D6 metabolism in women receiving adjuvant tamoxifen. Breast Cancer Res Treat. 2007:101(10):113-121. All rights in the product names of all third-party products appearing in this document, whether or not appearing with the trademark symbol, belong exclusively to their respective owners. Medco is a registered trademark and the Advanced Oncology Solutions logo is a trademark of Medco Health Solutions, Inc. Accredo and the Accredo logo are registered trademarks of Accredo Health Group, Inc., a wholly owned subsidiary of Medco Health Solutions, Inc. © 2010 Medco Health Solutions, Inc. IN40018C

HIGHER RISK of breast cancer recurrence.1

6. Specialist pharmacist discusses results and any implications for drug therapy change with physician

Real-time patient data

3x

Clinical Strategies: Breast Cancer IMPROVING OUTCOMES FOR BREAST CANCER PATIENTS

Advanced Oncology Solutions fosters better clinical outcomes by providing a broad range of services intended to optimize the effectiveness of breast cancer therapy.

THE PATIENT (hypothetical scenario): A 55-year-old postmenopausal woman with hypertension and well-controlled diabetes. She has two daughters, ages 30 and 27, as well as one sister who was diagnosed with breast cancer at age 55.

BENEFITS:

DIAGNOSIS

• Promote therapy regimen that meets clinical guidelines

Breast cancer that invades three lymph nodes, tests positive for estrogen and progesterone receptors and negative for HER2.

• Increase use of appropriate genetic tests • Apply appropriate coverage rules • Support administration of chemotherapy at efficient sites • Provide health education and counseling

THERAPY AND TREATMENT PLAN Her primary therapy includes partial mastectomy and lymph node dissection. Her treatment plan includes: • Local radiation therapy • Adjuvant chemotherapy as secondary prevention • Hormone therapy with tamoxifen for 2 years, switching to an aromatase inhibitor for the next 3 years

RECOMMENDED SUPPORT FROM ADVANCED ONCOLOGY SOLUTIONS Her case would be routed to our state-of-the-art Oncology Therapeutic Resource Center (TRC) where a team of breast cancer pharmacists will work with the patient’s physicians and take an active role in her medication-related care. We will: • Review therapy regimen guidelines, and dose and administration instructions • Support genetic testing through our Personalized Medicine Program to see if she is a poor metabolizer of tamoxifen and should immediately switch to an aromatase inhibitor • Apply appropriate coverage and dispensing rules for enhanced patient safety and cost control • Trigger utilization review to promote safe medication use and help prevent potentially harmful interactions with the drugs she is taking for cancer, hypertension, and diabetes • Work to mitigate short-term complications by deploying counseling services, including symptoms management and nutritional counseling

Over, please

• Apply bone health guidelines to support safe, long-term use of hormonal therapies • Promote adherence to oral anti-tumor medications and hormone therapies • If needed, support alternate sites of chemotherapy administration for selected therapies, such as white cell growth factors • Provide information on genetic testing to assist in determining familial risk of breast cancer

Therapy management related to specific breast cancer drug categories Medication Hormone therapies Aromatase inhibitors Arimidex® (anastrozole) Aromasin® (exemestane) Femara® (letrozole)

Route of Administration

Faslodex® (fulvestrant)

Intramuscular

2011



✓ (CYP2D6)

Oral

Taxotere® (docetaxel)

Intravenous





Drug Utilization/ Safety Review



✓ (HER2)

Infusion site

✓ (HER2)

Interaction with warfarin & phenytoin Interaction with sorafenib & erlotinib



Oral

Interaction with CYP2D6 inhibitor

Monitor cardiac function and cumulative lifetime dose



Intravenous Intravenous

Xeloda® (capecitabine)

Biologic therapies Herceptin® (trastuzumab)

Adherence Program

Bone health

Oral

Tykerb® (lapatinib)

Generic Substitution

Oral

Nolvadex® (tamoxifen)

Chemotherapies Anthracyclines Adriamycin® (doxorubicin) Ellence® (epirubicin)

Genomic Test



Monitor cardiac function CYP3A4 and CYP2C8 substrates Assess cardiac function

Note: Coverage rules are available for Tykerb and Herceptin.

MORE WAYS TO HELP CANCER PATIENTS In the near future, Advanced Oncology Solutions will introduce a variety of services on an a-la-carte basis. A concierge service will be offered for patients leaving the hospital that arranges delivery of oral medications in a timely and coordinated manner. Additional web-based technologies will alert patients when medication renewals and laboratory tests are required. We will also provide end-of-life counseling, including insight on advance care directives.

SEE HOW BETTER STRATEGIES YIELD BETTER OUTCOMES To learn more about how the Advanced Oncology Solutions clinical strategy can help protect your patients and your plan, contact your consultant or Medco or Accredo account/sales representative today.

The examples and photos in this document are for representative purposes only and do not depict an actual patient. All rights in the product names of all third-party products appearing in this document, whether or not appearing with the trademark symbol, belong exclusively to their respective owners. Medco is a registered trademark of Medco Health Solutions, Inc. Accredo and the Accredo logo are registered trademarks of Accredo Health Group, Inc., a wholly owned subsidiary of Medco Health Solutions, Inc. © 2010 Medco Health Solutions, Inc. IN40016E

Clinical Strategies: Prostate Cancer IMPROVING OUTCOMES FOR PROSTATE CANCER PATIENTS

Advanced Oncology Solutions fosters better clinical outcomes by providing a broad range of services intended to maximize the effectiveness of prostate cancer therapy.

THE PATIENT (hypothetical scenario): A 56-year-old man who discovers he has a level of prostate-specific antigen (PSA) which is elevated at 14 ng/mL on a routine screening.

DIAGNOSIS

BENEFITS:

The patient is diagnosed with stage two prostate cancer (Gleason score 8).

• Promote therapy regimen that meets clinical guidelines

THERAPY AND TREATMENT PLAN

• Apply appropriate coverage rules • Support administration of chemotherapy at efficient sites • Provide health education and counseling • Encourage adherence to oral and injectable therapy

The patient is treated with radical prostatectomy and clinical follow-up. Four years later, his urologist notes a rising PSA, with an eight-month doubling time. Anti-androgen therapy with Casodex® (bicalutamide) and Lupron® (leuprolide) is started. Narcotic analgesics are prescribed to alleviate pain from an area of bone metastases.

RECOMMENDED SUPPORT FROM ADVANCED ONCOLOGY SOLUTIONS His case would be routed to our state-of-the-art Oncology Therapeutic Resource Center (TRC) where a team of prostate cancer specialist pharmacists will work with the patient’s physicians and take an active role in his medication-related care. We will: • Review therapy regimen guidelines, and dose and administration instructions • Apply appropriate coverage and dispensing rules for enhanced patient safety and cost control • Trigger utilization review to promote safe medication use and help prevent potentially harmful interactions with the drugs he is taking for cancer or other medical conditions • Work to mitigate short-term complications by deploying counseling services, including symptoms management and nutritional counseling • Provide guidance on non-prescription therapy to maintain bowel health while on narcotic analgesics • Coordinate delivery of therapy regimen to prescriber’s office or infusion center • Help patients maintain or improve adherence to oral and injectable anti-androgen therapy • Review anti-androgen therapy against bone-health guidelines to help prevent development of osteoporosis • Support alternate sites of therapy administration for non-oral medications Over, please

Therapy management related to specific prostate cancer drug categories Medication Hormone therapies Casodex® (bicalutamide) Eligard® (leuprolide) Eulexin® (flutamide) Firmagon® (degaralix) Lupron® (leuprolide) Nilandron® (nilutamide) Trelstar® (triptorelin) Vantas® (histrelin) Viadur® (leuprolide) Zoladex® (goserelin) Chemotherapies Taxotere® (docetaxel) Emcyt® (estramustine) Novantrone® (mitoxantrone) Other therapies Nizoral® (ketoconazole) Megace® (megestrol acetate) Zometa® (zoledronic acid)

Route of Administration

Generic Substitution

Oral Intramuscular Oral Subcutaneous Intramuscular Oral Intramuscular Intramuscular Intramuscular Subcutaneous

Adherence Program

✓ ✓ ✓

Intravenous Oral Intravenous



Oral Oral

✓ ✓

Intravenous

✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓

✓ ✓

Drug Utilization/ Safety Review

Bone health

Bone health

Bone health Bone health Bone health

Cardio health



MORE WAYS TO HELP CANCER PATIENTS In the near future, Advanced Oncology Solutions will introduce a variety of services on an a-la-carte basis. A concierge service will be offered for patients leaving the hospital that arranges delivery of oral medications in a timely and coordinated manner. Additional web-based technologies will alert patients when medication renewals and laboratory tests are required. We will also provide end-of-life counseling, including insight on advance care directives.

SEE HOW BETTER STRATEGIES YIELD BETTER OUTCOMES To learn more about how the Advanced Oncology Solutions clinical strategy can help protect your patients and your plan, contact your consultant or Medco or Accredo account/sales representative today.

The examples and photos in this document are for representative purposes only and do not depict an actual patient. All rights in the product names of all third-party products appearing in this document, whether or not appearing with the trademark symbol, belong exclusively to their respective owners. Medco is a registered trademark of Medco Health Solutions, Inc. Accredo and the Accredo logo are registered trademarks of Accredo Health Group, Inc., a wholly owned subsidiary of Medco Health Solutions, Inc. © 2010 Medco Health Solutions, Inc. IN40017S