Prime analysis

Discerning duplicate drug therapy is not the patient’s job

Patients don't want to understand cross-benefit coordination of therapy. They're trying to get well.

August 31, 2020

People sign up for a health plan so they can see doctors. Not be one.

This patient struggled to manage the challenging symptoms of rheumatoid arthritis. The patient was prescribed Humira® by one specialist and Remicade® by another specialist. The prescriptions were written months apart. The drug list at each doctor’s office was not updated with the other drug. The patient didn’t know how that the drugs were duplicative. The result was a costly regimen for the health plan. But more importantly, this was a potentially dangerous situation for the member. These drugs can reduce the body’s immune system. The safety of their combined use has not been studied.

Humira and Remicade are both monoclonal antibodies that work by blocking certain immune responses. Both are expensive biologic drugs that can each be prescribed to treat several autoimmune conditions like rheumatoid arthritis, plaque psoriasis, Crohn’s disease, and ulcerative colitis. There is no clinical evidence to support taking them at the same time. They both work the same way, and have overlapping safety concerns.

Guidelines suggest that patients with autoimmune disorders working to manage symptoms should see a specialist every three to six months for medication adjustments. Prime’s research shows that less than 40 percent of patients with rheumatoid arthritis see their doctor even annually.1

$40,000 savings opportunity for patient with RA

Humira is billed under the pharmacy benefit. It comes in self injectables, vials and syringes. Remicade is intravenously infused over two hours by a provider. It’s billed under the medical benefit. Generally, pharmacy and medical benefit systems are not connected. This makes it vital to have clinical tools like Insights+ that can help to integrate and coordinate drug therapy across benefits.

Insights+ was able to identify that this patient was receiving both biologic products. Prescriptions came from two different specialists – each was unaware that the patient was using both products. Because of Prime’s integration of medical and pharmacy claims filtered through Insights+, Prime identified the overlap in drug therapy.

In this situation, the therapy plan was reviewed with both prescribers and the patient discontinued use of Remicade. Because of this intervention, the health plan saved $40,000 in annual costs while ensuring safe and effective medication use.

Insights+ is Prime’s total drug management tool that leverages the industry-leading Artemetrx data and analytics platform. It aggregates specialty medical and pharmacy claims data and uses it to identify patterns of high-cost drug use, cost and waste in the health care delivery chain. Prime is the only pharmacy benefit manager offering insights in the form of comprehensive benefits data that can be filtered and reported in ways to suit payer needs.

Insights+ reduces the complexity of managing specialty pharmacy costs. This lets health plans focus more on their members.

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