they are calling to ask a question. through our clinical intake we will find out maybe they have a case. they may have called intending to ask the expert something. if we lead them down the correct path we will open an expert medical opinion case because there may be information that we can have that true review of their records and provide that. critical care, again, not an often utilized service. we want be to assist you in really promoting through so your members are away. if it is a primary member, an active or retire re. we want to make sure they know enough that they can inform friends and loved ones this exist. often times when membership lands in an emergency room, i c.u. resolution in critical care

situation people aren't thinking about best doctors. the more we do to educate those people. that is another thing that comes with multiple years with our services they learn more. they realize we are not just expert medical service that is where they see value. we make sure the family knows about critical care to drive the care they are giving. treatment support is not as commonly used. i will talk a little bit at the very end of the work we are doing with abbey, particularly with marina and her team. they have asked a lot, and we think there is a lot we can do to leverage the all claims payer data base, the analytics in the areas of treatment decision support. this program is focused on certain conditions, about eight of them at last count, to really

drive engagement formu for musco skeletal issues. really trying to help drive did youtivelyization for those that might need is service that aren't aware. look at the member engagement piece. this is where we like to present information on how the member heard about us, how they got to us. i am very happy to report that abbey it wastic it was particule service team have a great understanding. we are doing more activities to get them to drive that. from 2017 to 2018, we increased those that responded.

they heard about us through the staff from 18% to 35%. they are doing a ton of work to understand the program and help refer members directly to us. the benefits website has gone from 10% to 19%. various other communications an listed. people find us through newsletters and things we are doing. i know there is more we can do. abbey and her team asked along with carol for additional assistance at giving people information not to annoy them or put more mail in their mailbox but to target the people who might need some of our services. when you look at the services we

provide, almost everybody in your population could benefit from one of our services at one time or another. just increasing the member engagement that way. we like to look particularly for the expert medical opinion. at the reason folks are calls us. most are the same year-over-year when we look at the top few categories why they called us. need help deciding among multiple treatments? they are diagnosed. they have treatment options but they need help deciding among treatment options they often contact us, have a case reviewed and get that. 50% in 2018 called us for that or contacted us for that. symptom not improving, 21% questioned the need for surgery which is important when somebody is facing a surgery this have an opportunity to ask an expert or they don't understand the

diagnosis. that is good to see that number fairly low. we think the medical community does a great job locally at informing people about the diagnosis. another thing we like to point out is member satisfaction. overall satisfaction from the membership who has used our services is 99%. that is on a 40% response rate. believe it or not, that is good. most of our clients we see in the 20 to 25% response rate. it is maybe driven by the fact they are calling us for a specific need and we usually ask them at the end about their satisfaction. often times when people get services and get taken care of, they are on the road and don't want be to complete the survey. it is great 4% of the pop -- 40%

of those that used us. 99% of those that used our services were satisfied. another thing we did or do for you on a quarterly bases definitely annually is break out demographic information so you understand the members utilizing our services specific to the expert medical pick. opinion. that is a lot of impact to members but also the cost of the plans. the first slide here actually breaks down demographically by main population groups. splitting out the active membership versus the two retiree populations. early retirees and medicare eligible retirees. of the expert medical opinion cases we opened or completed which was 194, we had 114 of

those were from the post 65 or medicare population. 64 of those 194 cases were active population. smaller portion of your overall demographics was 16 of those 194 cases from the pro-65 or recallly retiree population. is there more we could do with all of those populations? most definitely. we think we are just touching a very small peas and assisting a small portion of the population within all of those categories. -- categories. look at a different breakout. we have provided comparison numbers. looking at a couple different things.

first of all, breakdown male to female for expert medical opinion service. also looking at the membership being active and retirees primary members, those who came from the position of primary versus dependent. at the top we provided comparison listing hsf first comparing to the education and government sector, comparing clients of 25,000 plus employees and then our overall book of business. best doctors, all clients lumped together. just a couple of points. sfhsf leads the pack as far as age for those using our experted medical services. that is not a surprise based

upon the break out. your primary acreage for expert medical opinion is 60 to 69 age group. all of the others are in the 50 to 59. they are not lacking far behind, don't worry. that is where they fall when we look at overall. primaries is graphically at the bottom. if you are a numbers person or graph person you will need a magnifying glass to see the numbers. in summary on the left hand lower side of the graph we are looking at male versus female which is outlined at the top. for the number of cases out of that m194, 99 female and 95

male. a fairly even split as represented above. if you look at the right sidegraph, that is where we are looking at primary, active or retire rethat were primary employees in one stage of their lives. that is 156 of the 194. dependents were 38 of those. giving you a little split of demographics. we also know it is important to the board to really understand the impact of those expert medical opinion services that we are providing. ty know last year we provided this and again this year. these are the expert medical opinions we did. it looks at the dye agnostic

impact. you can see the dye agnostic impacts listed from no impact. when we reviewed it there was no impact to the diagnosis all the way to major impact to the diagnosis the 65% of the cases we reviewed were in the no impact or very minor impact categories. that just confirms the medical communities outstanding in the area. they are basically making the proper diagnosis for the members. kudos to the medical communities and providers you have access to utilizing. on the opposite end of the spectrum only 12%. only 22 cases out of 190 that were actually reported for this piece had a major impact to the diagnosis. that is important.

what was recommended? the next slide really looks at the dye agnostic details. for time's sake i won't go through all of the details here. you can see them but it really breaks out what the impact was for diagnosis. then we look at the therapeutic impact next. again, i will hit the high points. the magnitude of the therapeutic impact from no impact to major, great news. 50% of those expert medical opinions issued were in the no impact to minor impact category. your medical community does a great job. people are getting good care. there is another expert that could be involved in the care. only 15% from recommended

treatment or therapy impact were on the major side. again, details listed in the presentation i want be take you through all of those details. you probably understand from last year seeing those. really, to close my portion and i welcome questions. i didn't introduce john senior director of client management has worked closely with me on the account. joining in my calls monthly with abbey and her team. really what we are focused on and we will follow abbey's direction and always do. some of the things we have been starting to work on on your behalf are really driving member engagement. there is always more to do. the marketing team is trying to take a fresh approach.

we have a great team of people. one of the things we are doing is trying to make it campaign driven to items in the general news and public. world health day. when that happens we try to release the information related to that. we have been given a status internally with the marketing team as a partner. we will explore that. also exploring other ways to really focus on the great work marina and her team have done. there is more to drill into on that. >> any questions or comments? >> thank you very much. it was a nice summary. i have had the opportunity to look at all of the cases and review them. i would like to affirm the fact that it is quite clear that your

expert medical opinions. they are fantastic, they are very thorough. as the eye can be see from the reports, and i think that is really appreciated. i also think it is quite clear the members do appreciate and i suspect the 40% return rate and the 99% is pretty standard. i have a feeling the kinds of thoughtfulness and details which these cases are reviewed really shows up in your report. i am glad you didn't talk about cost savings. you opened that box. it was one case. that highlighted because although it was coded as sorted of intermediate impact. the fact is what was recommended for treatment for that person and that person had seen three

providers, a fourth was indeed a second opinion that other options were suggested in terms of other injections at other sites which weren't coded as an up code. it was sent clear to me the savings listed was just delayed a little bit because the injection that was recommended wouldn't work. >> the studies saying it would not work were not there. i am glad you eliminated the cost benefit. as we review this program we cannot make our decisions based on cost savings. i had an example where there was an individual who called because he had scatter racks. the cost -- cataracts.

the advice was don't drive at night. you can live with them for a while. that was a $12,000 cost savings. that highlights the number of cases where cost was arbitrary, and i think we should just as a board not really consider that. what did concern me is that there was a handful of cases where people really were stumped by what was going on. they had seen a number of physicians and getting muscle pill opinions. sometimes a third opinion, sometimes a fifth opinion. that is confusing but appreciated. there were a number of cases where people calmed to wanted to know if they needed surgery and they hadn't seen a surgeon.

for a member to call asking for a opinion on surgery when they hadn't seen a physician. it doesn't seem like a appropriate utilization of services. there are more that would do the surgery and hadn't referred or it was not accepted. there were cases where there was a huge cost savings claimed because the member was told nothing could be done. live your life as comfortable as possible and get hospice. my gut feeling when i read those sad cases. that probably was discussed in different settings. i don't know the health plans involved. the members need to hear that again. there was a huge cost saving by saying go home and take pain

medicine. to me from my review of the cases there were a number of instances where members had not really accessed the appropriate consultation to ask the questions face-to-face or if they had they got confusing advice and i didn't know what to do. we saw two surgeons at different treatment plans. the recommendation for a major treatment change and saved $20,000 but cost 9,000 in another. i don't fall the expert for that advice but to clarify this person really needed one of the options for him. the question i have for hss are there ways to help members clarify within the health plans

as they exist what the options might be. i want to congratulate best doctors for the expertise they called for. again i applaud and i can see why members like the service but it does raise other issues. >> i mean thank you for your presentation. i am gladna 99% of the members that have ulttillized your service were hospital be. what worries me. we hav have the members that the well but from the plans, 1% of the members uttill lie hlised

this service. we have not done any marketing. 60% of the members that utilized the service are retirees. those in the trades and sick maybe we have not done a good marketing for the members. visits from the providers. i don't think we have done good marketing in letting the members know that there is a service that they could have access to. >> there is the option of getting the questions answered by their physician or health plan. to that regard as the staff considers what its recommendation will be to the board at the next meeting we have asked the health plans to help us understand very clearly

how those services are offered and delivered and made available to our members and to the degree they are able to measure and report that as well. in order to give balance to what you have heard today. >> i would echo that. my last slide i didn't touch on all of the points. engagement, integration with health plan partners is an ongoing process. in some years we get more people in. other years we need to keep driving the engagement and integration. we have folk and the team is very intent on that. >> any other? >> one other comment in light of that. that is that of all of the cases reviewed, there was one case with follow-up where the member went back to his or her specialist.

it was clear the specialist appreciated the input of best doctors. i don't think anyone should leave the room questioning the value. a lot of the optimism over the change in treatment in terms of coding of that wa was there was anywhere from 10 to 100,000 of saving by avoiding emergency room visits or hospitalizations by monitoring blood pressure better, things like that. i am glad, please do not come back with cost savings. that is not an issue on which we can make he decision. >> i do want to affirm there is value in certain situations. i am not sure again how massive it is across the board. this may be where the value was. this may summarize where we

needed the value or what. >> i still have the original question in my mind a year ago about this investment as attached to the premiums of every member and how it is utilized. i will be profoundly interested in the staff recommendation. >> i would like to comment the plans we have need to step up with a second opinion in the plans. the city plan and united healthcare are doing fine. you can get a second opinion outside of your group. blue shield you cannot. they were pretty clear if you were sick you would not want to try because you would end up down here for an appeal which

you probably wouldn't feel like doing. they need to change policies. that should be done with negotiations this year. i think kaiser does. you probably know more how kaiser does a second opinion outside of their particular group. blue shield said you couldn't do it outside of the network, period. i would like the staff to look into that and do negotiations. >> i practice medicine sin in san francisco for 33 years. more hospitals that closed. several are open. i practice with everyone of these health plans. i will tell you that there was no problem when i saw somebody getting another opinion. despite what the plan said, i would say that the plan -- the people who responded from the plans didn't really understand what happens in the office with

caring providers, whether it was blue shield or kaiser or united healthcare because i know how i got second and third opinions, including out of plan opinions from the university. everywhere i practiced. i would be maybe more positive about the option based on the comparison to what we saw handed to us as options. >> every doctor or provider might not handle it as well. >> that is always the case. >> thank you. any public comment on this item? >> i am sure those closed hospitals had no reflection on your practice. i think you brought up some very important issues. what i find is that every couple

weeks i get calls from members who thank me for reminding them at the meetings we have best doctors and we try to put this in our newsletter. i have a plan to get information out to the actives. a lot of it has to do with the assurance or reassurance that the treatment they are getting is correct and the opinions they have are correct. even if it is a second opinion that is outside of their medical group or outside of their plan, a lot of members and i think this may have to do more with age and maturity and life experience that actives are very active and some of them are working hard and raising children. i think they don't always think of going for a lot of different opinions unless they get a pretty severe diagnosis for themselves or children or

spouses or partners. with retirees, it seems we have more time to it is around and talk to our friends and look more for that second or third opinion. sometimes they want some opinion that is completely unbiased. i think that is what best doctors offers. at least that is what they have said to us at rccsf that opinion made the difference. in some cases it made a treatment difference. in most cases it reassured them that what they were getting and who they were seeing were the best they could get and they were getting that appropriate treatment. it is that peace of mind. it is finding a physician they didn't know what is available or they felt they could make a decision on which of these five treating physicians they might choose and they found that the

information through best doctors was very helpful. for our population for retirees and early retirees we are really grateful for this benefit. we see it as worth every penny. we always want the lower rates. we have to understand this is offering something above and beyond for not a lot of money but for a great deal of pharmacy especially in the reassurance the treatments they are getting and the diagnosis are correct. we have very supportive of best doctors. >> . >> i represent to retired division. i would like to speak to best doctors. i used it twice in the past two years and found it very helpful. before best doctors i did go outside of kaiser but i had to pay. they wouldn't refer me outside

of kaiser. i think if you are saying that doctors and kaiser will grant you a referral outside of kaiser it must depends on who the doctor is. a lot of doctors are not willing to do. do that. i received a phone call from a member who couldn't come today to speak. she was diagnosed with cancer at can sear. -- cancer. they all recommended different treatment. she went to best doctors who sent her the information. with their help and taking their opinion back to kaiser she was able t to decide what treatment was best for her. she was very pleased with the best doctors report. it is important that kaiser should have to for the members if they are diagnosed with a

life-threatening condition or something that would greatly alter the scope of life, i think they should be allowed to have that type of opinion outside of kaiser at the expense of kaiser. it is always good to get a different opinion from what your network is saying. thank you. >> that is what i was talking about a serious condition you should be able to go outside of your group. any further public comment. seeing none. we will go to item 13. >> report on pharmacy landscape and trends. presented by mike clark from aon. >>

>> good afternoon. we have two primary objectives on the first page. doctor mills who is a aon medical director will present on education on the current pharmacy landscape and trends. what we see in the marketplace from the clinical perspective doctor mills can lend. i will speak about prescription drug tiering. there is a lot of information out there on cost of drugs so we want to level set the elements in this particular area in advance of potential proposals we may bring on re-tiering next month. i will turn it to doctor mill goemillsto introduce or conversn

pharmacy trends. >> i am doctor mills. grad to be here today. we are presenting this around the specialty drugs trends today considering the tremendous national focus as exhibited if the pharmaceutical hearings this week. on the very next slide what you will see is in the left lower hand corner as we try to go through the processes and feedback that happens today when a patient has a condition requiring treatment by a pharmacy drug. in the left lower side of the screen you can see the patient closes up in the clinical office and medications are prescribed. once that is prescribed there is one of two places that is going to provide financial

reimbursement for this. it may be under the medical. if it is something like an infusion. if it is something oral or subcutaneously through an injection, then that may be through the pharmacy piece. because the patient needs a medication. one click to the future. all of a sudden there is complexity most of the time neither the patient or provider is fully cognizant of. i think is best way to appreciate these i think that is a hexagon is to think about two supply chains. one is the supply of the drug. how does the drug get to the patient? the other is the financial arrangements. i am using plural. there are all kinds of arrangements so there is timely

delivery of the drug. typically what happens next is the patient fills the prescription at the retail pharmacy. of course, that pharmacy is part of some network that has been pre-arranged through incentives, contracts and maybe rebates. those rebates and those incentives and formula and what is required to get hands on the drug because medical evidence is established that it is appropriate has perhaps been done through the pbm. that is their full-time job. they are the intermediary or middle person, if you will, between the manufacturer and the retail pharmacy. what that means is that there is going to be certain amounts of

reimbursement depending where the member is in their life cycle in relationship to deductibles. on the other end you have the wholesaler who is holding on to these drugs and fording these to retail pharmacies when shelves are empty. forward one click. that is the employer. without a patient thissen wouldn't despise without an employer financing this, this couldn't exist. this is what we have today. there is a system that emerged over decades. it may be inefficient but is the system we have today. the employer may be eligible for rebates. there is another intermediary here because for sfhf it is the carriers dealing with the pbm. as we have heard in

conversations today these rebates potentially on quarterly basis flow back to this group right here. that is the highest level that i can keep it at without getting too entertaining or too complex. come complex. >> the carrier gets the rebates or kickbacks? >> they are supposed to be passed back to you. there was a conversation earlier today about that? >> how much? all of i it may not bet back. >> it can be millions. >> for instance last month in the blue shield presentation a lot of information on various aspects of the total claims and fees but within that we show the pharmacy rebates and if i recall

correctly approximately $6.2 million in pharmacy rebates paid back to hsf in 2018. if you recall we talked about how the claim persons for pharmacy and -- claim experience increased 7% before rebates were considered. because of substantial increase in 2017 the net increase was only about 2%. those rebates do come back and help support a suppression of trend for us as hsf is what we saw on the blue shield data. >> after reading of the hearing they were talking about full disclosure of the secret rebates. do we know what the rebates are before they give it to us?

>> in aggregates. >> pbm is middleman. that is what the hearings are about. we don't know what they are getting. they keep a percentage of it. that is what all of the hearings are about. there is not transparency here. >> we do know that hsf does the majority of the rebates for the united healthcare city plan and the blue shield access plus plans. the majority of the rebates pass to hsf. we have insight on what those are. the health plans keep a percentage. >> there is full transparency? >> well, we are not provided information on a drug by drug basis. we do receive aggregate information on the value of the rebates. what passes through to hsf versus what is kept by the uhc

for the city plan. >> just to clarify. i think part of the confusion is that there are independent pharmacy benefit manager companies that insurance plans contract with. i mean you see them advertised. they may not be doing the pharmacy benefit management in house but they may be doing it with another player, another party. i guess the question is for hsf blue shield of you california and kaiser do they manage their own pbms or contract with a third party to do that? >> so my understanding and if i speak incorrectly i ask healthcare representatives to correct me.

kaiser is all in house with blue shield. they are contracted with cvs health where blue shield manages the programs, formula, but the purchasing is based on cvs because of the leverage cvs health brings nationally and united healthcare similar arrangement with rx who is part of the broader health group organization. >> part of the concern of the hearings is what we have read about before. cvs and others may or may not have ordeals with pharmacy manufacturers to actually push their drugs. it makes it sound like they are on the street corners, but push their drugs.

>> you are right. there is a piece beyond the rebates. that is where the employers and payers and local governments have big concerns. what do those look like? how do you get to that information? >> that you have not diagrammed that? is that in front of us or not? >> i didn't diagram it because it is opaque. >> that is the point we are concerned about. >> it is fuzzy. >> let's go one click to the future because the next part of the slide we want to talk about the key trends what is happening and what is going to impact the pharmacy spin going forward. there is something called e scribing because you recall we were talking the patient and physician relationship when they

are prescribing medications there is technology to bring this information and cost savings to the clinic in realtime while they are prescribing the medication to a patient. they can look at benefits in realtime and see where the greatest incentive is, meaning least cost share for the member. that could have a real impact. that is actionable information the clinician can call in realtime, that could have an impact on the cost of care. they are driving this in the use of e scribing for clinicians. >> can we stop there? it would appear then that the pharmaceutical industry knows what each provider who is writing the prescription is prescribing or not. in fact, that is not entirely the case. i think, for example, when i was

in the practice, yes, that data was being forwarded by pharmacies to manufacturers. they knew how much drug x and y. they could target their advertising. my understanding having worked at kaiser for 16 years is that kaiser refuses to release the prescribing information of individual practitioners outside of their system to the drug manufacturers so if they tried to detail me on the street corner, they wouldn't know how much of their drug i was prescribing as opposed to another company's drug with a similar action. there is a line that may not be solid betwee pharma is that trus

it now a solid line? >> the only line i want to draw and hope the team will take away with is providers are provided much more information when they prescribe in realtime so the member is not showing up trying to get a prescription filled and there is a $700 could pay and they have to walk away and a lot of red type to get something they can afford. >> i assume that if there are alerts or warnings that the system can prevent errors. you are prescribing also now it alerts the prescribing provider what the member' member's co--py be? let'spretend there is a patient

that has gone through the process. the final diagnosis was rheumatoid arthritis. the doctor wants to spree scribe the latest and the best. the e scriber can point out there is a biosimilar where the member will have the least cost share of all. it makes sense for the member who hasn't been able to work because of the disability associated with the arthritis. on the first try the member is getting the care because the pbm will give the highest reimbursement to. that is the way to appreciate it, i think. >> thank you. we talked about e prescribing a major trend to change the way how they prescribe. another is and we have read about this in the newspapers.

you feel recall on thatgraph that right now the way these rebates work and we are talking about millions of dollars but somehow getting the rebates to go back to the member at the point of sale when the transaction is actually occurring when they fill the education making it much more affordable. that is a new trend. i think certain employers will consider this and some pbms say they will consider this or potentially do. that would be a flow of the dollars back to the member yielding savings right there. forward one click. the pbms themselves? >> there are recent mergers between pbms and health plans that may allow for more of the point of sale rebate dollars

going back to the members and better integration of data for risk scoring. another is this institution called icer which is a watchdog drug pricing industry group. it is the instituted for clinical and economic research. looking at in determining the true value of the drugs are and asserting what the price should be. this is done in europe and rent three introduced by the pbms here as well. in addition to looking at the published literature about the effect of the drug. this also looking at the quality and cost. and that is there whether it should be covered and what the appropriate price is. >> this has been in place for

quite awhile. it is o often involved in europe and canada by the licensing agencies to help decide on the value of introducing the new drug based on dollars per patient year of life or quality of life or whatever parameter. i didn't know how much this has been developed further because it was when it was proposed to our food and drug administration it is crude and dumb go anywhere. our fda does not look at these issues as they expend education. i didn't know this was going anywhere in our government regulatory agencies. you are saving some of the pbms are asking for this now? >> they are looking at it or saying they add this to the way

they look at certain drugs they may put on or take off the formula. the financial incentive you talked about between the manufacturer and the pbm may be one component. another are what are the quality adjusted life engineers? how much does this bring the member. it is financial and quality getting to the center of that, you know. >> will this data de transparent when they advertise their latest drug. somebody watching their kids play football would they advertise this is $800,000 per month of added quality of life? >> the way my understanding the way the clinical piece works there is a great deal of transparency and a panel of clinicians that serve on the

medical necessity committees through the u.s. in that decision is made it is sent to a different group. ir serve as a public watchdog. all information is public and you can review the reports online. i was checking over their work this morning. it was impressive. for the pbms, the opaqueness question i am not sure. i am not a spokesperson for them. i want that to be clear so i get out of here safely today. >> this red piece is cool. one of the key pieces that is a major trends to follow really closely are the new specialty drugs. they are expanded indications. there may be an original indication for adults and it is so successful at bringing a

better quality of life they want to expand to children. maybe it takes care of oneault to immune condition like arthritis maybe it can be expanded to include other conditions. next slide. for this slide here what is really interesting you notice the pie is bigger. that represents the total cost spent on specialty drugs in the u.s. back from 2012, a lot of these drugs were administered in an infusion site in the outpatient aspect of the hospital or physicians clinic. there is a huge chung that came under the medical carier. there has been this compelling trend that will continue where basically now half of this occur on the pharmacy side. these are specialty drugs that may be where the patient is

doing the injection themselves or maybe an oral drug filled under the pharmacy. specialty drug trend is to continue at 17%. we think this trend is going to continue. it will be greater than 50% in pay short period of time. one more click. i will talk more about the example of specialty pharmacy trends and expanding indications. we talked about this earlier. this is humira. in 2002 for those with rheumatoid arthritis and did not do well on generics. there was a new drug with a profound impact on the quality of life. because it worked on that autoimmune condition there were others they began to do investigations for. originally maybe the vo volume f

this drug shipped out every year was small. as the number of indications increased, those approved by the fda, chrohn's disease and then conditions for children. you can see that the spend on this is going to be bigger because there are more indications for which this has been approved. there is a 16% increase per capita in humira use alone from 2016 to 2018. next. one other big deal here is this example of biosimilars. it is a biological product, it is a large molecule made from another living organism or a plant. when it is biosimilar, it is similar in terms of effect and

safety in treating the same conditions for which the original was used to treat. we have snowflakes. at first they look identical. when you look close a few are different. to translate to the biosimilar. that means it is similar. the dialogue activity in suppressing an autoimmune condition. maybe the inactive ingredients in the infusion bag may be different. there is a tiny number today, only about seven. there are more applied for. they are not in the market yet today. i think one thing to help would be more competition, more biosimilars, more generics. i will head things back over. >> i am sorry to interrupt. if we think that expert opinions

and that raises, you know, anxiety among members. i can tell you the number of times i tried to convert someone from a brand to a generic drug made by the same manufacturer who failed the generic. that is the same drug but same manufacturer. now we are talking about biosimilar. what may be similar within the margin of study for allow ever many people these are tested on -- we will now have a responsibility that will be more intense to convince members to use biosimilars and not object. this may escalate, you know. the object for valid reasons. similar for 100 people may not be equivalent for the 101st

person. this is promising in terms of drug costs, it makes the market more complex for the provider who you started with. the provider patient relationship at the bottom left. >> from population health i am interested to see what happens to those grandfathered and be don't need to switch versus new diagnosis. there are power full incentives. these are 15 to 30% cheaper. i will be keen on the researches for those who decided to change when they are stable and doing great on another medication. it is a keen area of active research. >> thank you, doctor mills. on page 7 we are going to talk about prescription drug retailing initiatives. 85 to 95% of total prescriptions

dispensed are generic medications. that helps to both deliver very effective medications to your members and certainly aid and kind of helping to manage the overall cost of the medications across all three plans. two circumstances typically call the generic medications to elevate in price. that is the focus of the retailing initiatives. first is in your example you sited when a branded medication does lose the patent and there is an exclusive period for that manufacturer to produce a generic equivalent of that drug that launches on the marketplace during 180 day exclusive period.

when there is no competition, we find the price of that generic can only be marginally less than those of the brands. when you factor in the fact that brand of drug may have a rebeat, sometimes the met cost of the brand of drug can be less than the new generic during the manufacturer's exclusive period. that is one circumstance. something we have seeing elevated number of circumstances certain older generics who have manufacturers hugh are deciding to -- that are no longer manufacturing in that space. when the number dwindles there may only be one or two for that generic. that can leave those left to elevate prices in response.

these are the two circumstances that drive conversation around retiring or up tiering. some specific generic medications. you can see on page 8 what that can look like so trying to move away from this classic approach of calling drugs generic, preferred, nonpreferred and to more of a 1 through 4 approach. you can see how tier one is generic but can bring in lower cost branded medications or higher cost generics on page 7 moving to other tiers. >> from is a third scenario not as common as what you outlined.