Infusion and income: The ins and outs of infliximab

Medical drug management: the savings may surprise you.

February 27, 2019
Iinfliximab is the biggest piece (10 percent) of the biggest category (14 percent – autoimmune) of the largest section (50 percent – specialty drugs) of total drug costs.

Costs and use of autoimmune drugs are on the rise

The autoimmune category w¹as the primary driver of pharmacy spend (14 percent) in 2017.¹ This was fueled by big increases in both utilization and unit cost. The story of Prime’s management tools for drugs covered under the pharmacy benefit is well told in Prime’s 2017 trend report.¹

Remicade® provides a Prime example of how we deliver medical spend savings
Prime shows its health plan clients how PBM tools can be adapted to manage drugs under the medical benefit. (Remicade accounts for 10.5 percent of drug spend under the medical benefit.²)

Each drug requires its own strategic approach with its own analytics. Above all, a plan must coordinate strategy across both the medical and pharmacy benefit. Prime’s strategy for managing medical drug spend has evolved over two decades of working with our clients’ medical benefit data. It keeps the patient at the center of the decision-making process. It includes:

  • Formulary management
  • Network management
  • Utilization management
  • Clinical management

We use several of these strategies to achieve medical benefit savings for the drug infliximab.

In formulary management, clinical effectiveness comes first

Prime looked at all the infliximab drugs to make sure they could be considered clinically appropriate for patients. Prime advised clients that from a clinical perspective, Remicade, Inflectra® and Renflexis® are equally effective. The only difference was cost.

That makes formulary management a critical strategy for medical drug management. Prime negotiated rebates based on each client’s specific medical data.

Network management means site of care management under the medical benefit

Network management looks for cost savings by managing the location where drugs are administered. Infusions usually require a medical professional. Infusions can occur in many settings, including:

  • Hospital outpatient facility
  • Infusion center
  • Doctors’ office
  • Patient’s home

Remicade is reimbursed at an average sales price (ASP)+169% in a hospital outpatient setting. This compares to ASP+6% in a doctor’s office or infusion center. Prime’s site of care policy blocks reimbursement for infusions in a hospital outpatient facility. It redirects infusions to a lower-cost site of care, based on plan-specific provider data.

Our reimbursement solutions program recommends rates based on the medical formulary. This incents doctors to use the most cost-effective drugs.

Utilization management (UM) means drug review and claims edits under the medical benefit. Medical claims edits found an instance where Remicade was billed by a specialty pharmacy and shipped to the doctor’s office. A few days later, the drug was again billed by the provider directly. Prime stopped this duplicate billing and saved the client more than $30,000 annually per member.

Prime manages drugs and develops programs with integrated medical and pharmacy data. We do the research. We study the market. And in quarterly meetings with our Blue Plan clients, we share information, to shape and optimize the most effective medical drug management strategies.

This isn’t magic. No broad strokes strategy will cut costs across all specialty drugs. It needs the thoughtful approach of a PBM partner who knows your business, knows specialty diseases and knows your members. Research-based, strategic solutions for medical drug management are ready and waiting.


  1. 2018 Trend report
  2. Prime’s BoB, 2Q 2018

Drug names are the property of their respective owners.

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