After 20 Years of Humira Prescriptions, Therapeutic Interchange Programs Give Employers Much-Needed Options

Top 3 Things You’ll Learn

  • About half of specialty drug costs come from anti-inflammatory and dermatological prescriptions
  • Equally effective, significantly less expensive options may exist for the most popular brand-name medications in these categories
  • A utilization management program focused on these specialty medication categories can reduce unnecessary spend while improving member outcomes

Self-funded plan sponsors face a growing number of expensive anti-inflammatory and dermatology prescriptions, and they need a benefit advisor who can help them navigate a way to savings without negatively impacting their members. Over the last five years, the impact of specialty medication prescriptions has grown from affecting 1% of members to 2%, and that small group drives 50% of pharmacy costs. Specialty medications treat complex, chronic, and rare diseases, and drug manufacturers often charge more for these treatments that apply to smaller populations.

As benefit advisors look for ways to help plan sponsors reduce specialty drug costs, these two categories provide opportunities to lower spending while helping members find better outcomes. Focusing on putting each member on the right medication can help turn the tide for your clients.

Anti-inflammatory and dermatology drugs drive specialty drug trend

Autoimmune and dermatological condition diagnoses are growing for both millennials and baby boomers. Direct-to-consumer pharmaceutical ads and environmental conditions contribute to the growing spending. These two drug classes makeup up roughly half of all specialty drug costs for RxBenefits’ Book of Business in 2023.1

Though the population taking these drugs is small, the medications themselves are costly, and getting these members on the right drug at the right price can significantly impact plan savings from high-dollar specialty claims.

Plan sponsors and members don’t want to pay for ineffective treatments, and an independent clinical oversight program focused on these specialty medication categories can help prevent wasted dollars and improve member outcomes when the latest drug craze dominates the prescription pad.

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Member-focused intervention can be critical for better outcomes and decreasing specialty costs

Doctors may instinctively turn to some of the first lines of defense against autoimmune and dermatological conditions, such as Humira, Stelara, and Enbrel, but there may be a better fit for a member than these medications. When a member is new to a drug or therapy or has a newly diagnosed condition, starting them out on a lower-cost alternative to the highly publicized specialty medications may make both clinical and financial sense.

For example, Humira isn’t always the most effective treatment for a member with psoriasis, but doctors may prescribe it first because of its preferred formulary status. As pharmacy benefit managers and drug guidelines have evolved, there’s been a shift to allow psoriasis patients to start with treatments like Otezla, Taltz, or Cosentyx, which may make more sense fiscally and clinically. As physicians are shifting away from these prescribing habits, initiating open conversations around optimal treatments based on unique patient specifics can help increase adoption.

Members with autoimmune and dermatological conditions can experience ups and downs throughout treatment. It’s possible to have a member who’s been on a drug like Humira since its launch in 2003. The patient may be doing OK on the standard dose, but it’s equally possible that they’ve been taking double the normal amount for the past five years, which may indicate development of drug antibodies, decreasing the effectiveness of the medication. These treatment struggles throughout the years may be often overlooked, but an independent clinician may be able to identify the struggles in the life cycle of the member and have follow-up conversations with physicians.

An expert pharmacist can uncover what’s going wrong outside the doctor’s office by reviewing chart notes, speaking to patients, and going above and beyond to uncover what a medical provider may not have the time to fully investigate. By identifying opportunities to treat a member’s condition better, they may also uncover savings opportunities.

Benefit advisors who want to reduce specialty spend for these categories should ask:

  • What percentage of my client’s membership takes anti-inflammatory and dermatology drugs?
  • Do the drugs on this plan qualify for manufacturer copay assistance dollars?
  • Does the plan have a robust independent utilization management program where people look out for me, not their fees?
  • Is the plan only paying for what’s medically necessary?
  • Will members with these conditions get continual follow-up conversations with an expert looking out for their health and the health of the plan?

A new layer of Protect brings a laser focus on the top specialty drug categories and the total health of the member

The newest addition to Protect, RxBenefits’ client-aligned suite of clinical programs, is the High-Touch Therapeutic Interchange for Anti-Inflammatory Medications and Dermatologic Agents. The program provides patient advocacy and instruction for new patients and members with a history of using these popular treatments. By identifying the members who would benefit the most for intervention, our experts know where to focus resources to achieve the greatest savings.

When evaluating a specialty interchange recommendation, our expert pharmacists review the plan’s specific formulary, the unique treatment needs of the member, and the financial impact of the prescription when considering opportunities for intervention.

None of the changes recommended by this program are mandatory. The program aims to meet the patient where they are in their therapy, understand their needs and goals, and provide additional information to a provider to consider a therapeutic change when it makes sense.

The value of human intervention and the importance of member health cannot be overstated

By talking to patients and prescribers about the possibilities beyond expensive, name-brand specialty medications, utilization management programs can ensure the best possible therapy for each patient. The number-one focus for any utilization management program in a pharmacy benefit plan should be the members’ overall health.

Beyond the cost of the medication, there are opportunities for better outcomes for both the plan and the member. With periodic check-ins over the course of treatment, the member will continue to get the attention and treatment they need.

Through one-on-one conversations with providers, independent clinicians can have an open exchange of ideas about patient intervention. There’s value in additional oversight to evaluate the claims with information a specialist may not have time to incorporate into their discussion, and expert eyes on the prescription can be a bridge in the prescription continuum.

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