Costs and Risks Associated with Specialty Medications

Las Vegas—According to a retrospective review of a large payer’s specialty drug pharmacy claims from January 1, 2011, to December 31, 2011, 32.3% of patients who received a 90-day supply of an oral oncology drug did not fill the prescription a second time. Although dispensing drugs for chronic conditions in 84 to 90 day supplies are convenient, the authors concluded it was not worth the financial risk for payers.

These results were presented during a poster session at the PBMI conference. The poster was titled Cost Benefit Analysis of Dispensing Specialty Drugs for >30-day Supply.

The authors mentioned that specialty drugs typically cost >$2000 per month and are used to treat chronic conditions. Payers sometimes allow the drugs to be dispensed in greater than 30-day supplies, although the authors said the high costs and specialized handling and storage requirements may not be cost-effective. Payers may be at risk of patients not complying with their medications or discontinuing the drugs before the supply is finished because of adverse events, toxicities, dosing changes, treatment of advanced disease, and special handling and storage requirements.

In this study, the authors examined specialty drug claims in 2011 and categorized them by their days’ supply: ≤27 days; 28 to 30 days; 31 to 83 days; 84 to 90 days; and >90 days. They then reviewed claims that were for >30 days and analyzed associated plan-paid costs per claim.

The authors also categorized claims into low, medium, or high risk of noncompliance or discontinuation before finishing the entire days’ supply.

Low-risk medications included adalimumab, etanercept, glatiramer acetate, interferon beta-1a, and interferon beta-1b. Medium-risk drugs were alpha₁-proteinase inhibitor, darbepoetin alfa, enoxaparin, epoetin alfa, filgrastim, palivizumab, pegfilgrastim, and somatropin. High-risk drugs were antihemophilic factor recombinant, bexarotene, capecitabine, coagulation Factor IX recombinant, coagulation Factor VIIa recombinant, dasatinib, erlotinib, everolimus, imatinib, lapatinib, nilotinib, sorafenib, sunitinib, temozolomide, topotecan, and vorinostat.

For oral oncology drugs, claims were analyzed to assess the continuation after filling the first 90-day supply. The following oral oncology drugs dispensed as 84 to 90-day supplies were examined: everolimus, imatinib, topotecan, sorafenib, dasatinib, sunitinib, erlotinib, bexarotene, nilotinib, temozolomide, lapatinib, capecitabine, and vorinostat.

The average amount paid per claim was $2204 for <30 days’ supply, $7400 for 84 to 90 days’ supply, and $10,503 for >90 days’ supply. The average amount paid per claim was $7074 for 30 days’ supply of everolimus, $20,966 for 90 days’ supply of everolimus, $6892 for 30 days’ supply of sorafenib, $20,926 for 90 days’ supply of sorafenib, $4194 for 30 days’ supply of erlotinib, and $12,492 for 90 days’ supply of erlotinib.

The most common reasons for noncompliance or discontinuation of oral oncology agents included treatment of advanced disease, severe adverse effects or toxicities, special handling/storage requirements, frequent dosing changes, laboratory monitoring requirements, and high associated costs.

The authors added that medications considered low risk of noncompliance or discontinuation may still be associated with people not taking the drugs. They mentioned that most of the drugs require refrigeration or freezing and other specialized handling or storage requirements that may be affected by limited space for storage in the refrigerator, loss of power due to natural disasters, and drug delivery in the heat or hot climates. They also said that the World Health Organization has found people with chronic diseases often have poor adherence to their medications. Furthermore, studies have shown 15% to 41% of patients with multiple sclerosis discontinue interferon therapy within 3 years and 44% to 59% of patients with rheumatoid arthritis are no longer adherent to infliximab, etanercept, and adalimumab at 4 years.