ST. PAUL, Minn., April 6, 2015 /PRNewswire/ -- Hereditary angioedema (HAE) – a rare genetic disorder that results in potentially life-threatening edema or swelling of limbs, abdomen, face, tongue or larynx – affects about 20 in 1 million Americans and still fewer commercially insured members. Yet individuals with the condition are accumulating specialty drug treatment costs of more than $300,000 annually on average, and according to a new study by pharmacy benefit manager Prime Therapeutics LLC (Prime), those costs tripled in the last two years. Researchers will present the study on April 9 at the Academy of Managed Care Pharmacy (AMCP) 27th Annual Meeting and Expo in San Diego, and recommend programs to help people with HAE and their health plans manage their condition to help improve care and reduce the growing cost of HAE care.
HAE drug treatments can address acute attacks or help prevent attacks in people who experience frequent episodes. But the specialty drugs carry a significant price tag, ranging from about $5,000 to more than $11,000 per dose (wholesale acquisition cost). Prime set out to understand the use of HAE medicines in order to identify opportunities to improve management of people with the condition.
Costs need to be evaluated on both medical and pharmacy benefits because some drugs are given by infusion in a medical facility, and others can be self-injected. Hence, Prime researchers reviewed integrated pharmacy and medical claims for 12.5 million members between January 2012 and March 2014. They identified members with claims for one of four specialty drugs prescribed for HAE: Berinert®, Cinryze®, Firazyr®, and Kalbitor®. A fifth treatment available today, Ruconest®, entered the market in September 2014, after the study was completed, so it was not included in this analysis.
During the two-year study, Prime identified 17 in 1 million commercially insured members as having a HAE diagnosis. Further analysis revealed 212 members had used a HAE drug, with more than $69 million in HAE drug costs, averaging $325,675 per member. Furthermore, 23 people out of 12.5 million commercially insured members had more than $1 million in HAE drug costs. In total, $45,385,602 (66%) of HAE drug costs were paid through the medical benefit and $23,657,387 (34%) were paid through the pharmacy benefit.
Prime also identified that quarterly HAE drug costs nearly tripled in two years. Per member per month (PMPM) cost of HAE drugs increased 191 percent, from $0.11 in the first quarter of 2012 to $0.32 PMPM in the first quarter of 2014. Higher costs were partially driven by the number of members taking these specialty drugs increasing substantially. In the first quarter of 2012, 45 members received a HAE drug, compared to 118 members in the first quarter of 2014, a 162 percent increase.
"Costs for HAE drugs are increasing at the same time the number of people being treated is increasing, and a subset of people incurred substantial treatment costs," said Patrick Gleason, PharmD, director of health outcomes at Prime. "This analysis demonstrates how essential integrated medical and pharmacy benefit claims reporting is to understanding HAE drug use and costs. With the integrated data, we have a clear picture of use and costs and can build care management programs to help our members and their health plans make the best use of these specialty drug treatments, prevent waste and improve care."
While a very small number of people use HAE drugs, the increased use and costs call for high touch case management as an essential HAE management tool. Careful case management of high cost members could potentially result in considerable savings through dosage adjustment and decreasing drug waste.
Prime deploys utilization management strategies such as aligning policies across both the medical and pharmacy benefits, following set criteria for medical review and pharmacy prior authorization to ensure the right people are receiving the most appropriate treatment. Care management nursing assessments are available with plans to expand in the future.
Visit primetherapeutics.com to read more about the study.
About Prime Therapeutics
Prime Therapeutics LLC (Prime) helps people get the medicine they need to feel better and live well. Prime manages pharmacy benefits for health plans, employers, and government programs including Medicare and Medicaid. The company processes claims and delivers medicine to members, offering clinical services for people with complex medical conditions. Headquartered in St. Paul, Minn., Prime serves more than 26 million people. It is collectively owned by 13 Blue Cross and Blue Shield Plans, subsidiaries or affiliates of those plans. Prime has been recognized as one of the fastest-growing private companies in the nation.
For more information, visit www.primetherapeutics.com or follow @Prime_PBM on Twitter.
SOURCE Prime Therapeutics LLC