Autoimmune Seament Buraeonina.
ST. PAUL -- Over the past four years, spending on autoimmune drugs has doubled and utilization has jumped nearly 40% in a population of 4.4 million commercially insured members, according to recent new research from Prime Therapeutics LLC, a pharmacy benefit manager serving more than 22 million members nationally.
This research, studying the prevalence of use and cost of autoimmune specialty drugs using integrated medical and pharmacy data, was presented earlier this month at the Academy of Managed Care Pharmacy Nexus event which was held in National Harbor, Md.
Integrated data is essential for this drug category because a significant percent of expense for these drugs is covered by medical benefits, and medical claims diagnosis coding determines what conditions were treated with drugs covered by pharmacy claims.
The autoimmune drug class is one of the fastest-growing classes. There are now 15 specialty autoimmune drugs along with many traditional generic drugs to treat autoimmune conditions such as Crohn's disease, ulcerative colitis, psoriasis, psoriatic arthritis, ankylosing spondylitis, juvenile idiopathic arthritis and rheumatoid arthritis.
During the 2012 to 2015 study period, the Food and Drug Administration approved three new specialty autoimmune drugs, with a fourth approved in March of this year.
Among 4.4 million commercially insured members who were continuously enrolled from 2012 to 2015, 0.6% used at least one autoimmune specialty drug. The number of members using any of these drugs in a year increased 38.8% from 2012 to 2015, yet total payments increased 102.7%.
In 2015 these drugs accounted for about one in every 10 dollars of combined drug expense through the medical and pharmacy benefits.
Several specialty drugs are used to treat multiple conditions within the autoimmune class. For example, Humira is indicated for all seven conditions represented in this study, while other drugs may have an indication for only one condition.
"This overlap and diversity presents an opportunity for health plans to encourage the most cost-effective treatments through an indication-based formulary and utilization management programs," said Kevin Bowen, principal health outcomes researcher at Prime. "This research and Prime's integration capabilities provide the detail for a discussion with drug makers about indication-based pricing that may also help reduce overall health care costs."
The high expenses that have been associated with autoimmune drugs and other specialty medications have sparked criticism from political leaders, the managed care industry and consumer groups.
Prime also recently analyzed members' use of rheumatoid arthritis drug tofacitinib (Xeljanz) to find patterns and adherence behaviors. While use of the drug had been low (one member per 100,000 commercially insured members per month shortly after approval), it is steadily increasing.
The study found that potentially one in 10 members did not follow guidelines to use Xeljanz as a second-line therapy, and 44% had discontinued the drug at one year after starting therapy.