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.
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.