Specialty medications continue to drive plan costs for your clients. From the Inflation Reduction Act to the seven disease states to watch, these are the top specialty drug stats that benefit advisors need to know for 2023.
One high-cost specialty drug can drive plan costs of more than $250K for a given claimant in a single year. Specialty drugs are designed to treat a rare condition, one that impacts fewer than 200K Americans.
Two percent of a plan’s prescription drug claims will account for 50% of total pharmacy benefits plan costs this year.
A $3 million cure — two gene therapies for different types of hemophilia were approved in 2023. Roctavian, for hemophilia A, will cost $2.9M, while Hemgenix, for the less common hemophilia B, is expected to cost $3.5M.
Four extra years of protection will be given to biologics (specialty) drugs against price negotiations by the Inflation Reduction Act (IRA). Small-molecule drugs will be protected for nine years, whereas biologics will be protected for 13. Pharma’s already robust pipeline for specialty medications can be expected to grow as their focus on maintaining profitability will continue.
A five-month delay in progression compared to placebo was shown by Leqembi in early-stage Alzheimer’s disease. The drug was approved via the accelerated approval pathway and will be available for limited distribution. Up to 20% of all individuals with Alzheimer’s will be eligible for the drug, according to estimates.
Six months into 2023, the FDA accepted the Biologics License Application (BLA) for exagamglogene autotemcel for severe sickle cell (SCD) and transfusion dependent beta-thalassemia (TDT). This is the first gene therapy the FDA has considered, which uses the CRISPR gene editing platform rather than gene-insertion viral vectors.
Seven disease states to watch in 2023:
1) Dermatological conditions (psoriasis, atopic dermatitis, alopecia areata)
2) Anti-inflammatory conditions (Crohn’s disease, rheumatoid arthritis, ulcerative colitis)
4) Central nervous system conditions (narcolepsy, multiple sclerosis)
5) Viral conditions (HIV, HepC, HepB, etc)
6) Endocrine conditions (growth hormone deficiency, Cushing’s syndrome, infertility)
7) Respiratory conditions (cystic fibrosis, eosinophilic asthma, interstitial lung disease)
Eight of sixteen patients who received an individualized mRNA vaccine (autogene-cevumeran) post-surgery for pancreatic cancer had an immune (T-cell) response and remained cancer-free for 18 months. The most common type of pancreatic cancer, pancreatic ductal adenocarcinoma, is lethal in 88% of patients. BioNTech is now moving this vaccine to Phase II of clinical trials.
Nine biosimilars for Humira have been launched in the U.S. as of July 2023, and all the branded formulations offer some type of co-pay assistance. Multiple factors will continue to impact access to these biosimilars, including formulary status, interchangeability, and provider awareness.
Top 10 specialty medications by gross plan spend, according to RxBenefits’ 2022 book-of-business analysis:
As the pharmacy landscape continues to evolve, it’s clear no simple solution will protect plan sponsors from the growing specialty drug market. Finding new and innovative ways to assist self-funded employers will protect them from future risks, and beyond staying informed on the latest industry trends, benefit advisors need multiple solutions to help clients meet their benefits goals.