Everything you wish you knew about the autoimmune category

To manage autoimmune trend, bring together all the facts at hand

May 19, 2019

Do you know what your autoimmune trend is? Do you know what you are doing it manage it? Knowledge about the basics can go a long way in helping a health plan understand the market pressures that affect this category.   

A review of autoimmune (AI) fundamentals 

The autoimmune category has three big disease groupings. Each has distinct presentations and progressions. Drugs in this category often treat several conditions; plus, they can be processed under either medical or pharmacy benefits. 

Conditions: The autoimmune category is grouped into three major conditions:

  • 32 percent rheumatoid arthritis
  • 32 percent psoriasis and psoriatic arthritis 
  • 26 percent inflammatory bowel disease (which itself is divided into two-thirds Crohn’s disease, one-third ulcerative colitis)
  • 10 percent: a lot of other conditions

Drugs: Three autoimmune drugs are among the top ten individual drugs 

  • Humira® Pen (FDA approved to treat nine different AI conditions) 
  • Embrel SureClick® (FDA approved to treat five different AI conditions)
  • Remicade® (infliximab) (FDA approved to treat six different AI conditions) and infliximab biosimilars

Humira and Enbrel together make up 10 percent of all drug expenditures in the pharmacy spend. Remicade is the number one medical benefit expenditure drug.

When you dig just a little deeper, about 25 different specialty drugs comprise the list of those that treat autoimmune conditions. Because of their ability to treat multiple conditions, all together the 25 drugs are FDA approved for 80 different indications. 

Dual benefit involvement: Many of these AI specialty drugs are covered under the medical benefit. If a PBM doesn’t track medical and pharmacy claims by condition, they can’t track a single condition to understand its total cost of care and to uncover savings opportunities. 

Only Prime’s unique experience with medical and pharmacy integration can provide this depth of knowledge. Our 20 years of experience with integrated data helps us make specific and meaningful savings recommendations. 

QALY is not a bear in Australia

Quality adjusted life years (QALY): This is part of evaluating a drug’s cost effectiveness. It helps measure the value of a drug compared to another, or compared to not taking anything. What is the cost per QALY gained? 

The costs of most autoimmune drugs are very high. Clinical studies have traditionally worked to show the relationship between use of drugs and corresponding reduced use of other medical resources. Use of drugs in the autoimmune category do not typically produce medical cost savings to offset the cost of those drugs. QALY measures generally use a broader range of inputs to compare the cost of drug therapies on their ability to improve quality of life and lengthen life. This provides a more balanced way of looking at price to value. 

Spend is a dollar figure at a point in time; Trends track change, year over year 

We recommend that health plans know these numbers for overall pharmacy, for specialty and the autoimmune category. Drilling into the details is the only way to uncover opportunities for savings. 


Autoimmune category trend dominates the story of specialty growth


It is true that autoimmune trend is growing at a lower rate. But a modest change from 26 percent year-over-year growth to 19 percent growth offers little comfort. Compare this to the overall commercial pharmacy trend of near zero. This autoimmune trend comes from new drugs, drug inflation and increased utilization. 

Insights+ can uncover opportunities not seen before 

Our interactive web-based tool, Insights+ provides a simplified view of complex, integrated data. It helps clients identify opportunities to manage the financial side and improve the outcomes side. It finds trends over time that might not be evident from a book of business perspective. It gives us a new window for case management to reduce spend of high-cost members and optimize outcomes for people with challenging conditions. From a quality perspective, it identifies inappropriate use and finds opportunities to improve care. 

One way to ensure improve care is to make sure that treatment guidelines are being followed through utilization management and medical policies. Through application of these policies AI medication appropriateness is validated and formulary preferred AI drugs are used first. This optimizes manufacturer rebates or discounts that can offset the high AI drug price to value.

When assessing AI drugs price to value based on an ROI defined as direct medical care offsets, AI specialty drugs have a negative ROI of 10:1. You’d have to spend $10 in drug costs to save $1 in medical costs. That means two things:

  1. The price to value for these drugs is not in line.
  2. You’ll want to get the most from every dollar you spend on AI specialty drugs.  

That makes this category ripe for value-based contracting and other kinds of pricing guarantees. Prime has two of these value-based contracts currently for AI drugs: Cosentyx and Stelara. 

We’re all working for a sustainable health care system. Managing specialty drug costs does not mean denying members the drugs they need. It does mean asking tough questions about drug costs and value. 

It’s important that health plan clients understand the autoimmune category in the context of their total health care spend. Prime’s total drug management approach uses integrated strategies across the benefit divide. From the big picture – total autoimmune spend across all conditions, to costs by drug, by condition and by site of care — Prime’s offerings can identify opportunities to improve outcomes and control costs. 


Drug names are the property of their respective owners.

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)

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