Certain specialty drugs and a trend in opioid use have the potential to cost millions of dollars a year, according to research conducted by Prime and presented at the 27th annual Academy of Managed Care Pharmacy (AMCP) conference in early April.
Prime’s nationally recognized research draws attention to significant drug cost and safety issues, and highlights opportunities to improve care through utilization management (UM) programs.
Prime presented several new studies. Two studies looked at rare conditions for which new specialty drugs have been developed in recent years. This focus on “orphan” specialty drugs for rare diseases is providing new hope for patients. But these drugs often carry steep price tags.
Cystic fibrosis treatments
Prime researchers found that two groundbreaking treatments for cystic fibrosis may significantly increase pharmacy benefit costs.
Currently, the drug ivacaftor (Kalydeco) is available to treat a type of genetic mutation found in about 4 percent of people with cystic fibrosis, at an annual cost of $300,000 per patient.
And a new combination drug pending FDA approval could treat genetic mutations in up to half of people with cystic fibrosis. But if the combination drug carries the same price tag, the new medicine could add $150 million a year in new costs, just for Prime members and their health plans.
Nationally, it could cost our health system more than $3.8 billion to treat those with the 508del cystic fibrosis genetic mutation who are ages 12 and older. If the new combination drug gets approved for all ages, it could cost as much as $4.5 billion per year to treat the estimated 15,000 people with the 508del cystic fibrosis genetic mutation.
Hereditary angioedema treatments
A second study looks at four specialty drugs approved to treat a rare condition called hereditary angioedema (HAE). HAE affects 20 in every 1 million Americans and causes life-threatening edema, or swelling. Because drugs to treat HAE can be either infused in a medical facility or self-injected, both medical and pharmacy benefit claims were reviewed to track how these drugs are being used. Prime found that even though HAE is rare, use of HAE drugs added more than $69 million in drug costs over two years. During that time, annual costs to treat members nearly tripled.
In both studies, Prime researchers suggest using care and UM strategies, such as prior authorization and quality limits. These strategies could help improve safety and care, reduce the chance of medicine waste, and thereby reduce costs.
A third study focused on opioids (painkillers). Prime found that a significant number of members are taking these medicines for low back pain, headache and fibromyalgia, despite medical guidelines recommending against their prolonged use for these conditions. The research showed that 8.8 percent of members had at least one opioid claim during the study period. The most common diagnosis was low back pain.
Programs to identify these members and help them find the most appropriate pain treatment could improve safety and reduce costs for you and your employees, according to study authors.
This research has helped Prime and your Blue Plan develop thoughtful, member-specific clinical solutions, designed to work seamlessly for you and your employees.
To learn more about our latest research, please contact your Prime representative.
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