Prime Insights

By the numbers: Managing accelerating autoimmune drugs costs across benefits is critical

Prime Therapeutics | Nov. 8, 2016


Just 5 in every 1,000 members use autoimmune drugs. Yet it’s the most expensive drug class under both the medical and pharmacy benefit — and one of the fastest growing.

Autoimmune drugs account for one in every $10 spent on prescription drugs across the medical and pharmacy benefit.

Costs, use and pipeline are surging
Through the four-year period Prime studied (2012–2015), autoimmune drug use increased 38 percent, and spend increased more than 100 percent.

More than 15 autoimmune drugs exist, with many treating multiple indications and many more in the pipeline. Humira® and Enbrel® are the most widely used drugs under the pharmacy benefit, accounting for more than half of use. Remicade accounts for the lion’s share of use and spend under the medical benefit.

Controlling costs, improving outcomes starts with seeing the whole picture
As plan sponsors are faced with unsustainable drug pricing, particularly in the specialty class, active drug management across both the pharmacy and medical benefit is critical. Prime’s experts recommended a variety of strategies to accomplish cost control, while keeping member health and outcomes at the forefront. For the autoimmune drug class, some of these integrated strategies include:

  • Utilization management to ensure the right members are using the right drugs at the right time
  • Site of care optimization, encouraging members to use high-quality, cost-effective options
  • Exploration of indication-based formulary strategies
  • Formulary management to ensure the most clinically and cost-effective medicines are delivered at the lowest member cost share
  • Specialty pharmacy services including accurate and timely prescription processing, personalized, condition-specific care management, benefit support, and care coordination

To learn more about Prime’s autoimmune research or drug management strategies, contact us.


About Prime Therapeutics

Prime Therapeutics LLC (Prime) helps people get the medicine they need to feel better and live well. Prime manages pharmacy benefits for health plans, employers, and government programs including Medicare and Medicaid. The company processes claims and delivers medicine to members, offering clinical services for people with complex medical conditions. Headquartered in St. Paul, Minn., Prime serves just over 22 million people. It is collectively owned by 14 Blue Cross and Blue Shield Plans, subsidiaries or affiliates of those plans. Prime has been recognized as one of the fastest-growing private companies in the nation.  

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