Specialty medications have PBMs on edge

Sovaldi's price grabbed headlines, but PBMs are worried about the cost of long-term speciality medications
Sovaldi's price grabbed headlines, but PBMs are worried about the cost of long-term speciality medications

The HCV price war, which seemed to dominate the summer drug conversation, looked as though it was going to be superseded by new worry over the price of cancer medications. A Health Affairs blog post by execs at CVS Health, however, indicates that these fights are part of a much larger issue: the anticipated watershed in the specialty medication category itself.

PBM Prime Therapeutics touched on this concern in October, when it noted that specialty medications were expected to make up more than 50% of prescriptions by 2024. The significance is that although the class sounds small, specialty medications treat fairly prevalent conditions including hepatitis, multiple sclerosis and HIV.

The CVS execs, however, indicate the post-Sovaldi era should have payers on edge in part because the 12-week $84,000 regimen's cost seems to indicate a “resiliency in our system's ability to absorb costs.” They write that this is a cause for concern because the next wave of specialty medications — cholesterol-lowering PCSK9s from Amgen and Sanofi/Regeneron — represent specialty medications that have a potential to go beyond the familial hypercholesterolemia  patient population and reach into a larger pool of high-cholesterol patients that includes patients who cannot tolerate statins, or those who have had an insufficient response to this older — and cheaper — class of medications.  

In this instance, pricing expectations range from between $7,000 to $12,000 a year, every year, for decades.

In terms of totals, the execs estimate that hypercholesterolemia PCSK9 patients — 620,000 in the US — would represent a $16.4-billion market, while the statin-intolerant or statin-insufficiency population — an additional patient pool of around 3.2 million — would represent between $50 billion and $100 billion.

Pharma's PCSK9 optimism is evident by the $65.7 million Sanofi and Regeneron tacked on to speed the FDA's review of their alirocumab, in an effort to close the gap between their candidate and Amgen's, whose evolocumab landed in the FDA's to-review pile five months earlier.

Payers can intervene with health plans that nudge patients into pursuing cheaper options and a study by Avalere Health shows that some health exchange plans have even gone so far as to put MS and HIV drugs on the most expensive tiers, even when no generic is available.  

Avalere VP Caroline Pearson notes in the study that this can put a significant burden on consumers, but the October assessment by Prime Therapeutics found patients have a clear breaking point: co-pays that exceed $150 to $200.

This in and of itself has long-term payment implications, because of the physical and financial impact uncontrolled conditions can have on patients and their payers.The PBM used anti-inflammatory and MS drugs as a benchmark.


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