Annual drug costs increased $1.25 billion for members with more than $250,000 in annual drug spend – doubling in four years

Follow-up to 2016 study shows upward trend continues

October 19, 2020

Chris Knibb

EAGAN, Minn. – Rare disease therapy. One-time gene therapies. High-priced cancer drugs. These are all reasons why a consumer may have drug costs of $250,000 or more annually. In Prime Therapeutics’ (Prime) commercially-insured book of business, nearly 5,900 members passed that spending threshold in 2019, a 97% increase since 2016. And in 2019, those members accounted for $2.579 billion (9.7%) of all drug spend cumulatively through both the medical and pharmacy benefits.

Comparatively, Prime’s 2019 study, with three years of data, showed approximately 5,000 members in the “drug super spender” category, having more than $250,000 in annual drug cost – a 60% increase over 2016. Prime’s updated 2020 study shows the category of drug super spenders (high drug cost claimants) is a rapidly growing trend. If current trends continue, over the next five years Prime forecasts drug super spenders will account for more than 15% of all combined drug spend.

“This is an eye opener for our health plans,” said Patrick Gleason, PharmD, assistant vice president of health outcomes at Prime. “As pharmaceutical companies bring innovation to the marketplace improving the lives of many Americans, the number of super spender members will also continue to grow.”

Because there are only a few thousand super spenders, Prime is able to deep dive into members’ integrated medical and pharmacy claims to understand what drives these costs. Prime’s Specialty Monitor™ tool, launched in March 2019, helps health plans pinpoint costs and identify cost of care improvement opportunities for these members. Such improvements may include dispensing a drug from a more affordable setting (i.e., clinic vs. hospital) or working with the provider to optimize drug therapy (i.e., adjusting dosing to avoid waste).

“Health plans need to understand who in their member population are drug super spenders and who is predicted to become a super spender so together we can work with them to help find the most cost effective site of care and treatment regimen,” added Gleason. “This is a win-win for both the patient and the health plan.”

This research will be presented at the Academy of Managed Care Pharmacy (AMCP) Nexus 2020 Virtual event Oct. 19-23.

Download AMCP research poster

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