Top 3 Things You’ll Learn
- A small percentage of specialty claims make up a substantial portion of pharmacy benefit plan costs
- New gene therapies for hemophilia are emerging, bringing hope for treating rare conditions but also presenting substantial cost challenges
- A handful of Humira biosimilars have hit the market, creating potential for cost savings
Specialty drugs are at the forefront of the rapidly evolving pharmacy benefit landscape. Even for well-protected employers, understanding the drug pipeline is paramount. From the Inflation Reduction Act to biosimilars, here are 10 specialty drug numbers that impacted the landscape in 2023.
One high-cost specialty drug can drive plan costs of more than $250K for a given member in a single year. Even though these drugs are designed to treat rare conditions that impact fewer than 200K Americans, they’re still a major driver behind rising pharmacy costs.
Two percent of prescription drug claims will make up half of this year’s total pharmacy benefits plan expenses.
A $3 million cure — In 2023, approvals were granted for two gene therapies targeting hemophilia, with Roctavian for hemophilia A priced at $2.9 million and Hemgenix for the rarer hemophilia B expected to cost $3.5 million.
For an extra four years, biologic drugs will be protected from price negotiations under the Inflation Reduction Act (IRA). Regular small-molecule drugs will have protection for nine years, while biologics will have protection for 13 years. The pharmacy industry’s already robust pipeline for specialty medications can be expected to grow as the focus on making a profit continues.
A medication called Leqembi showed a five-month delay in progression compared to placebo in early-stage Alzheimer’s disease. The drug will be available for limited distribution now that it’s been approved via the accelerated approval pathway. According to estimates, up to 20% of all individuals with Alzheimer’s will be eligible for the drug.
Six months into 2023, the FDA made a significant move by accepting the Biologics License Application (BLA) for exagamglogene autotemcel, a gene therapy developed to address two critical blood disorders: sickle cell disease (SCD) and transfusion-dependent beta-thalassemia (TDT). This is the first gene therapy the FDA has considered that uses a gene-editing platform called CRISPR rather than using modified viruses to carry and insert new genes into a patient’s cells.
Seven disease states to watch:
1) Dermatological conditions (psoriasis, atopic dermatitis, alopecia areata)
2) Anti-inflammatory conditions (Crohn’s disease, rheumatoid arthritis, ulcerative colitis)
4) Central nervous system conditions (narcolepsy, multiple sclerosis)
5) Viral conditions (HIV, Hepatitis C, Hepatitis B, etc.)
6) Endocrine conditions (growth hormone deficiency, Cushing’s syndrome, infertility)
7) Respiratory conditions (cystic fibrosis, eosinophilic asthma, interstitial lung disease)
Eight of sixteen patients who received an individualized mRNA vaccine (autogene-cevumeran) post-surgery for pancreatic cancer had an immune (T-cell) response and remained cancer-free for 18 months. The most common type of pancreatic cancer, pancreatic ductal adenocarcinoma, is lethal in 88% of patients. BioNTech is now moving this vaccine to Phase II of clinical trials.
As of July 2023, nine biosimilars for Humira have become available in the U.S., all accompanied by co-pay assistance. Nonetheless, securing access to these treatments can be challenging, depending on coverage, interchangeability, and provider awareness.
Anti-inflammatory and dermatological condition diagnoses are growing. Learn how to navigate the rising costs for treating these conditions now.
Here are the top 10 specialty medications costing plans the most money, according to RxBenefits’ 2022 book-of-business analysis:
The specialty drug market is growing, and it won’t be slowing down anytime soon. There’s no one solution for employers to protect their plans from this growth, so staying informed and proactive is crucial to ensure your members get the best health outcomes without breaking your organization’s budget. Talk to your benefit advisor about building an effective benefits strategy to help your organization meet its business goals.
Learn more about finding the right solution for your organization.