Prime’s A-team: managing autoimmune specialty

The autoimmune category accounts for 14 percent of Prime’s drug spend. This was second only to diabetes in 2017. In an autoimmune disease, the body’s immune system attacks healthy cells. Common autoimmune conditions include rheumatoid arthritis, psoriasis and Crohn’s disease. Dozens of these conditions are extremely rare, affecting only a small handful of people across the country.

Three of the most common autoimmune drugs account for nearly 10 percent of Prime’s pharmacy drug spend in 2018. And the category continues to grow.

Like a lot of specialty, autoimmune drugs are often covered under the medical benefit. In fact, more than 25 percent of autoimmune specialty drugs are covered under the medical benefit.

Prime studies total cost of care by condition

That makes Prime’s unique connection to its Blue Cross and Blue Shield owners and clients so important. “We were one of the first PBMs to analyze both medical and pharmacy claims for autoimmune conditions, and then look at medical diagnosis codes to determine which drugs were used for which of the major autoimmune conditions,” Ramona said.

“That analysis helped us develop aligned strategies to control the costs of autoimmune drugs and help improve outcomes – whether they are covered under the pharmacy or medical benefit,” Ramona explained.

Many autoimmune drugs are used for several different conditions, but for different reasons. For the same drug, a utilization management program might specify a prior authorization for one autoimmune condition, and step therapy for another condition. “The UM criteria needs to specify the drug and the medical condition.”

Other major programs for the autoimmune category include site of care and reimbursement solutions.

Providing the right care, one patient at a time

“This is where it all comes together.” Ramona Powell explained. “Clinical, research, formulary, trade, benefit design, networks, reporting and analytics,” she lists them off on her fingers. “And all of us are thinking about how to make an impact for the individual patient with what we know. All of us come to the table.”