Break autoimmune (AI) into indication-specific info for actionable strategy

Prime analyzes the integrated medical and pharmacy data for 29 AI drugs

June 21, 2021

Prime uses integrated medical and pharmacy data and breaks down largest drug category (autoimmune) into indication-specific information; this maximizes data available for clinical programs and value-based negotiations

Autoimmune drugs are nearly 20% of total drug spend through the medical and pharmacy benefits. And one of the fastest growing expenditure drug categories with a 32% increase over 15 months.

But autoimmune is a diverse category of many drugs and many conditions; this study looked at 29 different drugs:

  • Each drug is approved to treat one to nine different AI conditions.
  • Some drugs are covered on a medical benefit; others on a pharmacy benefit.
  • Collectively less than 1% of commercially insured members use one of these therapies.
  • An individual’s AI drug therapy may have significantly different average costs, depending on the condition.
  • Some conditions have generic drugs or biosimilars available for treatment; others do not.

Among a 15 million-member commercial population, Prime looked at individuals taking one or more autoimmune drugs – in 2Q2020 the count was 614 per 100,000.

Prime examined and cross referenced integrated medical and pharmacy claims data and available UM information. With this detailed analysis, Prime was able to separate use of the 29 drugs into disease categories. This allowed Prime to track treatment cost by condition.

For many autoimmune conditions, the drug costs alone make up most of a member’s total cost of care.

The analysis also showed variability in drug costs by diagnosis. One drug’s cost may vary widely per patient by indication because of different dosing, site of care, frequency, duration of use, and more. This presents an opportunity for health plans to encourage the most cost-effective treatments through indication-based preferred drug lists and pricing.

This also has impact for value-based contracting. With this data, Prime can differentiate a drug’s indication and cost valuation for pharmaceutical manufacturer value-based contracting discussions.

Based on this groundbreaking research, Prime now offers autoimmune condition-specific reporting to its health plan clients. Tracking treatment costs by condition makes the development of care management and clinical programs more effective.

Prime analytics help clients identify safe, cost-effective use of therapies and provide them with insights to make data-driven business decisions.

Prevalence and Cost of Autoimmune Specialty Drug Use by Indication in a Commercially Insured Population, January 2019 through June 2020 (Spring 2021)
Prevalence and Cost of Autoimmune Specialty Drug Use by Indication in a 4.4 Million Member Commercially Insured Population Continuously Enrolled Four Years, 2012 to 2015 (Fall 2016)

Related news


July 22, 2024

Oncology Insights: 2024 ASCO Annual Meeting key findings

Findings from this year’s American Society of Clinical Oncology (ASCO) Annual Meeting will likely lead to clinical practice changes and U.S. Food and Drug Administration (FDA) drug approvals or expansions


July 16, 2024

LISTEN NOW: Beyond the business – Stories of corporate kindness | Pharmacy Friends Podcast

In this episode, we talk about how our employees' help goes beyond our work in health care, aiding in philanthropic efforts


July 12, 2024

August 2024 decisions expected from the FDA

Your monthly synopsis of new drugs expected to hit the market