Managing Specialty Pharmacy Costs

San Antonio—To better manage specialty pharmacy costs, managed care plans can look at a number of areas that drive up costs, such as copay coupon programs, as well as ways to reduce medical and pharmacy costs for high-cost diseases, such as autoimmune diseases. These were some of the issues discussed by a panel of experts in an AMCP meeting session titled Specialty Pharmacy Insights: What Are Managed Care Plans Doing?

Lida Etemad, PharmD, vice president at Pharmacy Management Strategies, and Mark Godwin, PharmD, manager of clinical pharmacy at United Healthcare, opened the session by placing in context the challenge of copay coupons on specialty pharmacy costs. For non-specialty drugs alone, it is projected that the use of coupons will add $32 billion to healthcare costs over the next 10 years. The reasons for this include the rapid proliferation of manufacturer-provided copay coupon programs over the last several years and the tendency of coupon programs to promote use of higher cost medications over lower cost alternatives. The impact of coupons on payers is often higher costs, according to the speakers.

To limit the impact of these higher costs on specialty pharmacies, Drs. Etemad and Godwin spoke about the strategies used by United Healthcare Pharmacy to incentivize the use of products with more affordable cost structures. Among their strategies is a Specialty Pharmacy Collaboration program that no longer facilitates coupons for select tier 3 medications. Initiated January 1, 2013, for members in the Designated Specialty Pharmacy program, 6 medications are currently in the program and include drugs for multiple sclerosis (MS; ie, interferon beta-1b and fingolimod), transplant (ie, mycophenolate mofetil), rheumatoid arthritis (RA; ie, adalimumab), and hepatitis C (ie, boceprevir capsules and peginterferon alfa-2b). All of these drugs have lower tier alternatives available.

To implement the program, United Healthcare Pharmacy undertook what they called a High Touch Member campaign in which they sent letters to prescribing physicians 60 days prior to the program roll-out and to members 45 days prior to the program roll-out. Members were presented with 2 options: (1) they could move to the lower cost option and the specialty pharmacy would facilitate the new prescription and prior authorization for the new drug; or (2) they could continue on the current drug and pay the full cost share as defined by the benefit plan.

To examine the impact of this program on costs, they tracked the largest member base, which was transplant patients on tumor-necrosis factor (TNF) drugs. Of these members, 43% were interested in the lower cost alternative. Of the patients who switched from adalimumab to the lower cost alternative, significantly more were older and women, with the lowest rate of switch found in the northeast area of the United States. They found that the rate of switch was similar for patients with psoriasis, psoriatic arthritis, RA, and patients with multiple conditions. The lowest rate of switch to a lower cost alternative drug was in patients with Crohn’s disease and those with no evidence of TNF-related diagnosis.

Baseline utilization characteristics and benefit plans also affected the rate of switch among members. Patients with higher baseline costs in general had higher switch rates, as did those with a greater number of baseline medications. In terms of benefit plans, significantly more patients with higher insurance cost sharing switched. However, patients with a deductible in their plan did not have a higher switch rate.

Based on the success of the program, the presenters said that an additional 25 medications are being added to the program in 2014. These medications include drugs for growth hormones, hepatitis B and C, infertility, MS, neutropenia, pulmonary hypertension, RA, and transplant.

When managing specialty drugs, Patrick Gleason, PharmD, director of health outcomes, Prime Therapeutics, LLC, emphasized the need to target the cost of drugs and drug class used by the high-cost members in a health plan. At Prime Therapeutics, they identified that the drugs used for autoimmune disease (ie, adalimumab and infliximab) incurred the highest expenditure in 2012 of $800 million. “Understanding spending for autoimmune drugs on both the medical and pharmacy benefits is complicated yet essential when managing the specialty autoimmune drug class,” he emphasized. 

A program initiated at Prime Therapeutic to manage the class of drugs for autoimmune disease, he said, resulted in the company realizing over 30% savings in this drug class. Overall, Dr. Gleason noted that the reduction of costs in this class of drugs was trimmed by comprehensive management that reduced the cost in channel management (1%-3% savings), utilization management (5%-7% savings), and contract activities (20%-25% savings).

“Identifying the factors driving pharmacy costs under both the medical and pharmacy benefit will assist health plans and plan sponsors better manage care through evidence-based treatment algorithms, drug distribution channels, contracting activities, and care coordination,” he said.