HealthSystem Specialty Pharmacy Exchange COVID19 June 12 2020

Health-System Specialty Pharmacy Exchange: COVID-19 June 12, 2020 1

Today’s Discussion Objectives § To provide updates on how COVID-19 is impacting the health-system specialty pharmacy landscape § To provide actionable insights on operational changes required § To review a real-world experience dealing with COVID-19 on the front lines of health-system owned specialty pharmacy Meeting Format and Flow § Casual sharing environment § Insights gathered from our guest speaker, internal Shields experts, and our partner health-systems will be shared § Use the chat feature to ask a question or provide additional insight into a topic area § Meeting is being recorded and a transcript with chat based additions will be made available and shared 2

Today’s Speakers Health-System Strategy Team, Shields Health Solutions Erin Hendrick Chris Paciullo Stephen J. Davis With significant input and support provided by our expert peers within Shields Health Solutions 3

Today’s Guest Speaker Darren Lowe Director of Contracting, Shields Health Solutions 4

COVID-19 in the United States § Restrictions have started to loosen, universally § Many states continue to see hospitalized patients rise, especially post-Memorial Day § Elective surgical case volumes remain low; clinic visits are rebounding as a mixed bag of telehealth and inperson visits § Health-systems have continued to watch NOI plummet, independent of local COVID-19 trends 5

Specialty Pharmacy Has Demonstrated Significant Resiliency to Date March April May June Operating Revenue (Rx)* 25% 5% 6% 9% Average Days Supply Dispensed* 10% 8% 5% Total Specialty Appointments (Health System)* 15% 30% 17% 10% New Patient Starts (Rx)* 20% 40% 30% 17% *compared to January/Feb run rate ^ as of EOD 5/20/202 • Revenues have remained strong and June is demonstrating rebound growth • In March, revenues outpaced the increase in “average days supply dispensed” by a significant amount This appears to have normalized through June but longer days supply is appearing to be the norm • Specialty appointments have rebounded, as a mixture of in-person and telehealth visits • New patient starts are rebounding as well 6

Outlook § Return of clinic volumes § June is showing strong growth towards a return to budget, as a mixture of telehealth and in-person visits § Overall specialty prescribing has not changed dramatically during COVID though specific disease states have been severely impacted § Hep C new starts have deferred; RA has waned § Unclear how to budget visit volumes for next 12 months § Deferral of care impact § Significant concern has been expressed about the impacts of a 4 -month delay in seeking care across the continuum 7

HRSA § Immediate Enrollment § The Health Resources and Services Administration (HRSA) has announced that, in response to the COVID-19 pandemic, it “is allowing some entities, upon request and review, to immediately enroll into the 340 B Program. ” § In a new notice on the 340 B Drug Pricing Program homepage, HRSA notes that every Friday, beginning Friday, April 10 th, it will post a supplemental Medicaid Exclusion File that includes a list of entities who have been approved for immediate enrollment. This list is in addition to the quarterly MEF posted on the 340 B Office of Pharmacy Affairs Information System. § Additionally, covered entities no longer need to wait for to file their cost report before requesting eligibility for a child site Abbreviated Health Records • During this time, an abbreviated health record may be adequate for purposes of the 340 B Program. The record should identify the patient, record the medical evaluation (including any testing, diagnosis or clinical impressions) and the treatment provided or prescribed. For purposes of 340 B Program eligibility, the record may be a single form or note page. • In addition, in a situation where volunteer health professionals are providing health care, emergency documentation should be generated to make the relationship between the provider and the covered entity clear and to make clear the covered entity’s responsibility for providing care. This documentation should recognize the emergency nature of the situation, the name and address of the volunteer, and his/her relationship to the clinic, and should be kept on file by the covered entity. Telehealth Audits • HRSA understands that the use of technology in health care delivery during this time is critical, and that telemedicine is merely a mode by which the health care service is delivered. For the 340 B Program, HRSA recommends that covered entities outline the use of these modalities in their policies and procedures and continue to ensure auditable records are maintained for each eligible patient dispensed a 340 B drug. *Make sure your telehealth visits align with your splitter / location file logic* • Based on the current COVID-19 pandemic, HRSA is moving towards conducting 340 B Program covered entity audits remotely (virtually) for the next several months 8

Is Telehealth here to stay? It is estimated that there will be ~1 Billion Telehealth visits in the United States in 2020 (900 M related to COVID) https: //www. healthcaredive. com/news/medicare-seniors-telehealth-covid-coronavirus-cms-trump/578685/ 9

Preparing for a surge in Telehealth Visits § In October 2019, ~1/10 Americans had ever used a Telehealth service § 1 in 8 Americans had a video Telehealth visit in April 2020 § 35 million Americans lack access to broadband internet “We’ve seen telehealth adoption that would have taken 3 -5 years occur in just two months” Coverage for Telehealth § March 2020 – CMS Expands coverage for Telehealth benefits § April/May 2020 – Commercial insurers (Humana, BCBS, UHC) began adopting more lenient Telehealth polices. § Significant variation among regional/local plans (Opt-out) § Many only through end of 2020 § AFP and AMA released guidelines on the use of Telehealth along with a list of vendor options. 10

Survey of Consumers’ Health Care Behavior During COVID-19 11

Survey of Consumers’ Health Care Behavior During COVID-19 12

Survey of Consumers’ Health Care Behavior During COVID-19 13

Survey of Consumers’ Health Care Behavior During COVID-19 14

Shields Health Solutions COVID-19: Payor and PBM Changes Discussion Objectives Darren Lowe Director of Contracting, Shields Health Solutions § PBM policy changes due to COVID § Relaxation of PA’s, quantity dispense, and refill too soon rules § CMS 855 S enrollment changes § Extended turnaround times for network enrollment § Other 2020 changes in the payor landscape § M&A activity § Infusion reimbursement / site of service 15

PBM COVID-19 Related Policy Changes Currently In Effect 16

PBM COVID-19 Related Policy Changes Currently In Effect (con’t) 17

COVID-19 Implications on Network Enrollment On March 23, 2020, the Secretary of the Department of Health and Human Services provided a broad 1135 waiver on enrollment screening requirements, application fees, criminal background checks, site visits, and certain licensure requirements. For a pharmacy enrolling as a CMS-DME provider through CMS-855 S form, this has materially shortened the window between application submission and enrollment effective date: from 8 -10 weeks down to about 4 weeks Conversely, both Express Scripts (ESI) and Caremark have seen an expansion of turnaround times for new pharmacy network enrollment applications: • ESI is running 45 -60 days; up from 15 -30 day • Caremark is running 90 -120 days; up from 45 -60 18

Additional 2020 Trends in the Pharmacy Payor Landscape Industry Consolidation • Aetna acquisition of Caremark • Cigna’s acquisition of Express Scripts • Caremark becoming the PBM for Anthem (branded as Ingenio. Rx) • Prime Therapeutics outsourcing most of its PBM business to Express Scripts • Optum’s acquisition of Diplomat Focus on ‘Buy & Bill’ Reimbursement ü Many payors are seeking lower reimbursement rates for provided administered drugs (typically infusions) currently reimbursed via the medical benefit ü One strategy is to eliminate the ability of the health system to buy & bill and require that the drugs come from a limited network of specialty pharmacy – UHC attempted enact this strategy for a set of 47 drugs on April, 1 2020; however they delayed implementation due to COVID-19 – Cigna is expanding this policy change to nine additional drugs as of September 30 19

Next Steps Health-System Strategy Team, Shields Health Solutions ehendrick@shieldsrx. com cpaciullo@shieldsrx. com sdavis@shieldsrx. com • Collate chat questions, hints, anecdotes • Please reach out to us with any information you want to share or questions for the network you may have • Summary documents will be sent out 20

Health-System Specialty Pharmacy Exchange: COVID-19 June 12, 2020 21