All year long, we as a pharmacy benefit manager monitor the pharmacy landscape and track our client and member data to identify issues contributing to drug trend and spend. Our review of CarelonRx 2022 drug trend data1 provided insights into rising drug costs, as well as the clinical and cost-control strategies we applied to address primary drivers of spend.
Pursuing our goals of optimizing whole-health outcomes while lowering the total cost of care once again delivered measurable results for our plan sponsors and members in 2022. How did we do it? Let’s take a closer look at trends around some leading drivers of cost and utilization, and CarelonRx programs designed to mitigate them.
CarelonRx insights applied to keep trends in check
Efforts to keep trends in check over the year were a real success, and were especially impactful in the specialty drug space, where many of the largest cost drivers are found.
In fact, specialty medications account for nearly 60% of the spend (medical + pharmacy) for CarelonRx clients, though only less than 3% of our member population utilizes specialty medications.2
We took deliberate steps to curtail specialty trend in 2022--and succeeded, with a low overall specialty (medical + pharmacy) trend of 2.1%.
In 2022, we kept trends in the very low single digits.
- 1.3% Overall drug trend (Medical + Rx)
- -0.01% Non-specialty drug trend
- 2.1% Specialty drug trend (Medical + Rx)
Additionally, for more than half of CarelonRx clients, we held the specialty trend down to single digits or below, with nearly forty percent of clients experiencing a negative specialty trend.
48% of clients had a single digit or lower specialty trend, and 38% of clients had a negative specialty trend.3
Inflammatory conditions: understanding the impact
Complex, chronic conditions and the therapeutic drug classes used to treat them have remained a huge contributor to rising drug costs for years.4 At CarelonRx in 2022, inflammatory conditions were the number one driver of spend.
In 2022, the top three conditions driving spend were:
1. Inflammatory Conditions = 18.2% of drug spend
2. Cancer = 16% of drug spend
3. Diabetes = 6.9% of drug spend
Inflammatory conditions, also known as autoimmune diseases, are the third most common cause of chronic illness in the United States.5 These conditions,6 including Rheumatoid Arthritis (RA), psoriasis, and inflammatory bowel disease (IBD), are characterized by the body’s immune system attacking its own healthy cells, tissues, and organs.
These conditions place a notable burden on patients, payers, and employers, including long-term treatment costs and the potential for decreased work-related productivity.
Many patients with inflammatory conditions require the use of specialty medications, including biologics, to alleviate symptoms and reduce the immune response associated with their disease. Treatment with these specialty drugs plays a critical role in managing the health of our members with complex conditions.
Inflammatory conditions: drug spend
Top trend drivers for this drug category include biologics like the Tumor Necrosis Factor-α (TNF) Inhibitors adalimumab (Humira) and etanercept (Enbrel), as well as Interleukin Inhibitors, like ustekinumab (Stelara), risankizumab (Skyrizi), and guselkumab (Tremfya). In 2022, three of the top five pharmacy spend drivers were drugs used to treat inflammatory conditions, including adalimumab (Humira), risankizumab (Skyrizi), and ustekinumab (Stelara).
Trend in this class is driven by multiple new drug approvals, expanded indications, new formulations, and direct to consumer advertising.
Also, it’s important to note trends that have been related to changes in the Humira biosimilar landscape with new, lower-cost treatments moving through the pipeline. In this category of drugs, deliberate shifts in the market, made in preparation for the launch of competing biosimilars, have been driving factors. These tactical changes from manufacturers that affect utilization, as well as a number of expanded indications, had a considerable impact on trend in 2022.
Trend mitigating strategies
We continue to respond with strategies that promote exceptional, holistic care while hedging against these considerable cost drivers.
Millions in overall savings were delivered through our quality-focused Site of Care program, which ensures members have access to the highest-quality care in the most cost-effective setting, depending on their clinical need. This program resulted in $56 million in overall savings in 2022, which translated to $1.93 PMPM in savings.7
We're also combatting the growing cost of specialty drugs through our Cost Relief program, which allows members to get virtually all specialty medications with $0 out-of-pocket cost by optimizing manufacturers assistance dollars available for specialty drugs, taking the guess work out of copay costs.8 The program also includes personalized enrollment support and outreach by specialists who manage and coordinate complex and expensive specialty medications. Our Cost Relief program delivered savings of up to $10-12 PMPM for our clients in 2022.9
Our utilization management (UM) programs allow us to ensure our members receive appropriate treatment regimens, doses, and schedules as well as mitigate leakage by adhering to our evidence-based clinical criteria. Enhancements to these UM programs have led to incremental savings for our inflammatory condition members in 2022. For example,
- With expanded criteria for the Targeted Immune Modulator (TIMs) agents, we were able to address potential excessive dosing and have been seeing savings of up to $5500 per claim10, all while ensuring patient safety and alignment with FDA labeling.
- We continue to partner with our enhanced personal healthcare providers to ensure safe and effective treatment for our members. We were able to identify members who were receiving potentially duplicative therapies for inflammatory conditions and work together with these providers to save nearly $2000 per claim for avoided duplicative therapy10.
Looking ahead: putting insights into action
Today, complex conditions are increasingly able to be treated with new, often costly, drugs.
An enormous share of new drug approvals has been for specialty drugs, including biologics, and this pipeline is poised to continue its growth trajectory. The FDA approved 37 new drugs in 2022, with 27 of them being specialty drugs. As these new agents come to the market and new uses are approved for additional disease states, there is more availability of more costly treatments for more patients.
Here are some of the ways our data-driven insights are developing into forward-looking solutions for the specialty drug benefit in the coming year and beyond:
Biosimilars entering the marketplace have been making headlines, especially in the anti-inflammatory drug category. At CarelonRx, our approach to biosimilars mirrors the rigor of the rest of our clinical and evidence-based approaches, ensuring our strategic decisions prioritize clinical efficacy while also balancing taking into account cost-effectiveness to achieve optimal clinical outcomes.
CarelonRx added Humira biosimilars effective December 1, 2023. Adalimumab-adbm (lower list price version) is added to all CarelonRx commercial formularies. Cyltezo is added to select commercial formularies. Both will be at parity with Humira. By continuing to monitor the pipeline, CarelonRx can support biosimilar adoption while driving competition and increasing access to cost-effective new treatments.
We expect additional biosimilars to be FDA-approved and available in 2024. We will continue to respond with strategies that promote clinically appropriate care first and foremost, while hedging against considerable cost drivers in historically expensive specialty drug classes.
BioPlus Specialty Pharmacy was acquired by Elevance Health in 2023. Starting in 2024 and, depending on employer locations, most CarelonRx plan members will transition to this new specialty pharmacy. Together, CarelonRx and BioPlus provide compassionate care that’s tailored to members’ whole health, offering medication therapy management programs to help optimize pharmacy care. Other features include convenient and easy-to-use digital tools, such as:
- Pay by text
- 2-click prescription refills
- Digital signatures for home medication delivery
Our Rx Guide solution is further enhanced. Rx Guide offers high-cost claimant reporting for employers and consultants, and we are making it even easier to view integrated specialty drug spend occurring on both the pharmacy and medical benefit for this population of plan spend drivers. Additionally, the tool offers the capability to drill down into those high-cost claimants, enabling a level of detail that can help support employer/client decision making for benefit or plan updates. Clients may choose to add predictive analytics to help identify which members might have high-cost claims in the future.
We are using deep insights to develop data-driven solutions that can empower better budgeting and decision-making capabilities for plan sponsors. This includes methods for delivering spend forecast summaries and curated benefit recommendations to better control future specialty spend. In addition, patient-centered priorities like proactive outreach by risk levels and personalized interventions led by a dedicated team of clinicians means the future of specialty care with CarelonRx looks strong indeed.
In conclusion
We recognize that our specialty member population typically has conditions that require drug treatments which can be high-cost. This population also tends to have comorbid conditions that add complexities that suggest a need for more tailored care to help optimize their health and encourage preventive wellness.
We are proud to be building on the success of our high-performing programs as we continue the essential work of managing inflammatory conditions and the impacts of specialty therapies.
1 Methodology: Pharmacy and medical de-identified drug utilization data (with all personally identifiable data removed) was analyzed for the Commercial group population, representing approximately 7.5 million members, with pharmacy and medical coverage carved in. Pharmacy-dispensed specialty and non-specialty drugs, and medically covered specialty and non-specialty drugs administered under the medical benefit (excluding inpatient site of service), were included.
Clients contractually prohibited from inclusion were excluded. Integrated trend statistics assessed the change in gross spend (net of rebates), which included drug ingredient costs (under medical and pharmacy), as well as pharmacy-specific taxes and dispensing fees. Medical administration costs were not included.
Total trend comprises utilization trend and unit cost trend. Utilization trend is defined as the rate of change in total days’ supply per member per month. Unit cost trend is defined as the rate of change in treatment costs due to inflation, prescribing practices, and CarelonRx trend — management strategies that drive decreases in the unit cost of drugs, thus decreasing drug trends.
Costs of COVID-19 vaccines are excluded from all drug trend data.
There is no universally accepted definition of a specialty drug, and there are differences in payer specialty drug lists, client spend, and trends. CarelonRx defines specialty drugs as injectable and noninjectable drugs typically having one or more of several key characteristics, including but not limited to:
- Frequent dosing adjustments and intensive clinical monitoring to decrease the potential for drug toxicity and increase the probability for beneficial treatment outcomes.
- Intensive patient training and compliance assistance to facilitate therapeutic goals.
- Limited or exclusive product availability and distribution.
- Specialized product handling and/or administrative requirements.
- High cost.
2 CarelonRx Specialty Conditions Value of Integration (VOI) Study 2022 (formerly known as IngenioRx): carelonrx.com.
3 CarelonRx data for plans with 100 or more members.
4 Formulary Watch: Spending on Specialty Drugs Maintains Double Digit Growth [accessed December 5, 2023]: formularywatch.com.
5 U.S. Pharmacist: Trends in Selected Autoimmune Diseases [accessed December 5, 2023]: uspharmacist.com.
6 Inflammatory conditions include: Acrodermatitis, Ankylosing Spondylitis, Hidradenitis Suppurativa, Inflammatory Bowel Disease (including Crohn’s Disease, Ulcerative Colitis, Gastroenteritis, and Colitis), Iridocyclitis, Myocarditis, Pericarditis, Psoriasis, Pustulosis, Rheumatoid Arthritis, Sarcoidosis, and Uveitis.
7 $1.93 PMPM breakdown: $1.22 per member per month in direct savings for our clients as a result of site of care criteria implementation, and an additional $0.71 in sentinel savings through growth in adoption of the program.
8 Members who have a high-deductible health plan with a health savings account are required to meet their deductible before they can receive a $0 copay.
9 Net savings after fees.
10 CarelonRx internal data 2022.
