Express Scripts going to value pricing for inflammatory drugs

arthritis

Express Scripts rolled out a value-based reimbursement model this year for cancer drugs designed to make sure patients get the right drugs and clients save some cash. Next up: anti-inflammatory meds, a category that includes Humira, the world’s best-selling drug.

The PBM giant today said that beginning Jan. 1, 2017, it will repeat the value-based reimbursement model with drugs for rheumatoid arthritis, psoriasis and Crohn's Disease. It said that in 2015, the biologics used to treat these conditions became the costliest therapy class in the U.S., accounting for nearly 10% of total pharmacy spend. AbbVie’s ($ABBV) Humira raked in $14 billion dollars last year and is on pace to exceed that this year.

To achieve its goals, the PBM will use its Accredo specialty pharmacy to help educate patients and keep them on track taking their meds but then refund up to $6,000 if a patient discontinues any preferred anti-inflammatory medication within the first 90 days, it said today.

“Painful inflammatory conditions like rheumatoid arthritis can cripple patients and obliterate payer budgets," Dr. Glen Stettin, chief innovation officer for Express Scripts, said in a statement. He said the PBM is taking on that challenge by using “creative ways to take better care of patients and protect our clients' budgets.”

Drugs for Inflammatory disease have traditionally been lumped together in formularies, even though are made up of different conditions that range from rheumatoid arthritis to skins conditions like psoriasis, to Crohn's disease, which is an inflammation of the bowel. Express Scripts intends to treat each condition separately, with meds approved for each one.

That will allow it to pit niche drugmakers against those that make non-specific drugs to extract bigger discounts. It is a practice that it has used with great success against Gilead and its pricey hep C meds Sovaldi and Harvoni, claiming to have cut the cost of the drugs across the category by 50%.

Express Scripts in its announcement did not mention how its program for inflammatory drugs might be affected by the launch of several biosimilars of some of the biggest sellers in the category in the next year. The FDA has already approved a copy of Amgen’s Enbrel, while Amgen’s copy of Humira won the unanimous backing of an FDA panel in July and is expected to be approved soon. Payers, however, have said that given price hikes that the branded drugmakers have employed ahead of the competition, costs of copies will be high enough that not that much total savings will be realized when they hit the market.

The value-based reimbursement program is one of 6 that Express Scripts now has in place, most of which are aimed at conditions that rely heavily on new specialty drugs, which are used by only 1% to 2% of U.S. drug consumers but which accounted for 37% of the total drug spend last year. The PBM has forecast that while total drug spending will grow 6% to 8% between 2016 and 2018, spending for specialty meds, including those for inflammatory conditions and cancer, will jump 17% annually over the next three years.

So, in addition to inflammatory, cancer drugs and hep C drugs, Express Scripts has a program in place to keep the new PCSK9 inhibitors for high cholesterol from being used routinely, given that they cost $14,000 a year, compared to pennies per pill for most generic statins for treating high cholesterol.

But its attention is not solely on specialty drugs. Last week, it rolled out a value program for diabetes care. In that program, it is guaranteeing per-patient spending caps for its clients. It acknowledged participating plans will still see their costs for diabetes care grow but claims their price increases should be about half of the forecast growth of 18% through 2016 and another 17.7% in 2017.

- here’s the release on the inflammatory drug program 
- and here the release on its diabetes effort

Related Articles:
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Specialty-drug spending set for double-digit leaps over the next 3 years: Express Scripts
Are PCSK9 meds worth the cost? Only if Amgen, Sanofi and Regeneron slash prices by two-thirds: JAMA
Express Scripts: Strict prior-auth moves keep a tight lid on PCSK9 sales
Payers say dramatic savings from biosimilars a mirage, offset by price hikes