Prime rolls out new medical benefit management offering

July 8, 2021
by Angela Maas

As published in AIS’s Radar on Specialty Pharmacy

(Content reprinted with permission. Original article available on AIS’s website, available by subscription only.)

As payers continue to look for ways to tackle the rising spending on specialty drugs, Prime Therapeutics LLC is launching a medical drug management program. Known as MedDrive, the offering will be rolled out in phases, with the initial one focused on increasing the use of biosimilars.

Last year, specialty drugs made up more than half of total drug spending for the first time. That trend shows no signs of slowing, as the pharmaceutical pipeline is full of specialty agents, including biosimilars. As of early July 2021, the FDA has approved 29 biosimilars, although not all have launched due to patent litigation. An IQVIA report published in September 2020 estimated that these products could decrease drug costs by $100 billion by 2024.

In April, Prime released a white paper on biosimilars indicating that the company “will actively promote the evidence-based use of biosimilars (and other low-cost drug options),” a position endorsed by the company’s pharmacy and therapeutics (P&T) committee. Prime is collectively owned by 19 Blue Cross and Blue Shield Plans, subsidiaries or affiliates of those plans; the PBM serves nearly 33 million people across 23 Blues plans. The P&T committee is made up of independent, practicing physicians and pharmacists who cover 25 medical and pharmacy specialties, as well as senior leadership from Prime’s Blues plans.

AIS Health, a division of MMIT, spoke in early June with Joseph Leach, M.D., chief medical officer at Prime about the company’s use of biosimilars and the launch of MedDrive. The following interview has been edited for length and clarity.

AIS Health: Will you select preferred biosimilars? If so, will you have a minimum number of biosimilars approved before you take this approach, and, if so, what is that number?

Leach: Yes, Prime will be selecting preferred biosimilars in many cases. There isn’t necessarily a threshold to the number of preferred biosimilars available on the market to prefer a product. Prime is evaluating many clinical and financial factors and providing client-specific reporting and insights to help health plans take actions that are best for their specific market. However, for the drug lists, alignment across our plans is strongly encouraged to maximize the overall savings available to our clients.

AIS Health: What criteria will you be looking at to prefer a biosimilar? Is it mainly price since they’ve already been approved by the FDA?

Leach: Yes, we are looking to lower health care costs for our plans and members. We worked closely with our P&T committee members, who are practicing physicians and clinicians representing various specialties that use specialty drug treatments, to examine the safety and effectiveness of all 29 biosimilars currently approved. They support Prime, and its Blue Plan clients take the position of encouraging use of biosimilars for all indications that a reference biologic product is approved to treat.

AIS Health: Will there be any provider and/or member outreach around this phase?

Leach: Yes. Prime is currently working on materials to help our plans communicate with members and prescribers on the safety and effectiveness of biosimilars and their interchangeability as clinically appropriate. We are still in the early stages of this product so plans will be determining outreach strategies over the remainder of the year and how best to communicate with them about the importance of using biosimilars. Minnesota Oncology, which is where I practice, is supporting use of biosimilars as interchangeable to help aid these cost-savings measures. Oncology is an area that has historically had some of the highest cost medicines, so it’s important to look in this category as an opportunity to achieve considerable savings. Autoimmune is another class with several biosimilars on the market.

AIS Health: Will members already on a reference product be grandfathered in?

Leach: Ultimately, this will be up to the plan, but Prime supports immediate transition to a biosimilar product given they are highly similar with the same therapeutic effect anticipated. We have been doing this in my practice and have found good acceptance by both providers and patients.

AIS Health: Will reference drugs still be on formulary but at a higher tier? Or will they not be covered at all?

Leach: They will be managed through medical policy, requiring trial of the preferred product prior to use of any nonpreferred drugs.

AIS Health: When is the first phase launching? Do you have plans already signed up for the program?

Leach: The first phase is underway, but timing varies by program and client. Some clients can implement as early as July 1, 2021, or anytime thereafter. Additionally, state-specific requirements on notification of changes may impact implementation timing.

AIS Health: How many phases will there be total, and when will they launch?

Leach: We anticipate at least two phases, possibly more. We expect the first phase to take [place] approximately through 2021. We are in the planning process for the second and subsequent phases at this time.

AIS Health: Could you please give a little color on the other elements of the program?

Leach: MedDrive combines Prime’s medical drug management solutions all in one product to help clients manage costly medicines and align to help realize these savings. Prime is harnessing the collective strength of Blue Plan alignment on preferred drug lists to drive to the lowest cost drug options, including preferring biosimilars when it helps members and plans get the right drug at the lowest possible cost. MedDrive also includes other market-leading, cost-saving strategies supported by analytics and reporting, medical policies and clinical tools, consultative services to navigate the growing specialty landscape, provider and member education and support, and more. We will add more tools to the MedDrive toolkit as the program expands.

AIS Health: Do you have any projected savings from the first phase that you can share? What about the MedDrive program overall?

Leach: This is a multiyear strategy, and the biosimilars as a cost savings driver is key. We expect that medical drug management strategies, such as maximizing medical savings and preferring biosimilars, can lead to hundreds of millions, if not billions, of dollars in medical drug savings for health plans over five years.

AIS Health: Other PBMs say they manage the medical benefit, so if this program is the first of its kind, how is it different from what others are doing?

Leach: Managing spend across both pharmacy and medical is a challenge for most in the industry due to a lack of integration. But given our partnership with market-leading Blue Plans, with this product add Prime is in the unique position to deliver fully transparent total drug management solutions. When plans come together around interchangeability of biosimilars and prefer the lower-cost options instead of high-cost reference brand biologics, they can obtain market-leading savings. It’s not only the first program that aligns its health plan clients to leverage market share and drive savings, but it’s also bringing key parts of the health care industry together — such as providers, specialty pharmacies, manufacturers — to help ensure biosimilars are accepted and used as equally safe and effective treatments so people can benefit from the most appropriate drug at the lowest net cost drug.

AIS Health: Is there anything I’ve neglected to ask that you’d like to add?

Leach: Prime has been achieving success with biosimilars already and tested these strategies in advance of launching MedDrive. In the oncology class, one client shifted use of biosimilars from single digits (0%-25%) to 80%-90% and saved several millions of dollars. If all clients adopted this strategy, savings would be considerable. For example:

  1. Prime recommended moving from Avastin to biosimilars (Mvasi and Zirabev). Six months after adopting the strategy, the client achieved total biosimilar market share greater than 90% (up from 25% and 2%) and saw several millions of dollars in savings (Q3-Q4 2020; category oncology).
  2. Prime recommended moving from Herceptin to biosimilars (Kanjinti and Trazimera). Six months after adopting the strategy, the client achieved total biosimilar market share greater than 90% (up from 23% and 1%) and saw several millions of dollars in savings (Q3-Q4 2020; category oncology).
  3. Prime recommended moving from Rituxan to biosimilars (Riabni and Ruxience). Six months after adopting the strategy, the client achieved total biosimilar market share greater than 80% (up from 0% and 2%) and saw several millions of dollars in savings (Q3-Q4 2020; category oncology).

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