Reining in the Galloping Specialty Drug Spend | 2022 PBMI Annual National Conference

Kali Panagos

As drug costs continue to climb because of the price and utilization of specialty medications, drug manufacturers and third-party organizations have come up with a variety of ways to make them affordable for patients with high out-of-pocket costs because of a high deductible, coinsurance — or no insurance at all. But those programs can be challenging to evaluate, Kali Panagos, Pharm.D., executive vice president, consulting & clinical at ARMSRx, a pharmacy benefit consultant, said yesterday at the three-day 2022 Annual National Conference of the Pharmacy Benefit Management Institute (PBMI) in Orlando, Florida

Specialty medications now account for 55% of pharmaceutical spending in the United States, up from 28% in 2011, according to IQVIA. The proportion is growing because spending on drugs for HIV, autoimmune disease and cancer have increased. Industry observers expect biosimilars to Humira (adalimumab) next year and to Stelara (ustekinumab) in 2024 to moderate the trend in spending but only partially. Humira has been approved as a treatment for a number of conditions, including rheumatoid arthritis, plaque psoriasis and hidradenitis suppurativa. Stelara is apprved also approved as a treatment for plaque psoriasis as well as ulcerative colitics and Crohn's disease.

Panagos stressed it’s important for pharmacy benefit managers (PBMs) and health plans to develop a management strategy and formulary placement now for the waves of biosimilars coming on the market.

“Most of the PBMs are still figuring this out and haven’t made a conclusive strategy on where they’re going to place these and other biosimilars,” she said.

Copay assistance programs have increased in the pharmacy benefit space, she said, and nearly all PBMs will have some type of program around copay assistance. With the use of these options, specialty drugs are not carved out from the pharmacy benefit plan and rebates remain intact.

Alternative funding mechanisms, however, remove specialty drug coverage out of the pharmacy benefit plan and the rebates no longer apply. Patients are often required to meet financial eligibility requirements. However, the full cost of the therapy may not be fully covered and there may be fees.

Panagos said, however, some state regulators have expressed concern about these types of programs. “Certainly use them for your members to offset their costs. But keep a very close eye on the laws by state by state that could change the utilization of these programs and impact,” she said.

There are other strategies, sometimes specific to certain drugs, that PBMs and plans should consider using to lower costs. One example she mentioned was a plan that assisted a patient in enrolling in a clinical trial in the patient’s care facility for Trikafta (elexacaftor/tezacaftor/ivacaftor and ivacaftor), a drug to treat cystic fibrosis. The savings to the plan was $290,000 year. Panagos also said that there may be clinically appropriate interventions to manage costs. She cited the example of patient who was started on a lower starting dose of Korlym (mifepristone) to treat Cushing’s syndrome. The savings was $48,000 for the claim.

Data are important to the overall evaluation of any program, Panagos commented. “Auditing and having access to your pharmacy data is important for evaluating whether these programs are the right fit for you and for making the best-informed decisions.”