Prime Therapeutics Finds Drug Costs Drive Nearly Entire Cost of Care for Hereditary Angioedema

Insurance Weekly News

By a News Reporter-Staff News Editor at Insurance Weekly News -- The cost of specialty medicines to treat someone with hereditary angioedema (HAE) - a rare genetic disorder that results in potentially life-threatening swelling of limbs, abdomen, face, tongue or larynx - was more than 97 percent of the total cost of care, according to new study by pharmacy benefit manager Prime Therapeutics LLC (Prime). The findings suggest pharmacist case management is necessary to optimize drug therapy. Prime researchers will present the study at the upcoming Academy of Managed Care Pharmacy's (AMCP) Managed Care & Specialty Pharmacy 30th Annual Meeting April 23-26 in Boston.

The study found HAE specialty drug use occurred in 15 per 1 million commercially insured individuals with a $400,000 average annual HAE specialty drug cost.

For the study, Prime analyzed pharmacy and medical claims data for its 15 million commercially insured members and found 226 members who had at least one claim for an HAE drug in the first half of 2016. Prime researchers followed the 226 members for 12 months after their first HAE drug claim to determine drug use patterns, hospital and emergency room visits and total cost of care. The average 12-month total cost of care was $409,925, with HAE drug cost totaling $395,507 (97 percent) and all other medical and pharmacy costs equaled $14,418 (3 percent) of the total cost of care.

Of the 226 members with an HAE claim, 111 (49 percent) met continuous enrollment criteria. Forty-eight (43 percent) of the 111 members had claims for two or more HAE drugs and 10 (9 percent) of those had more than $1 million in HAE drug spend. This small group accounted for 30 percent of the $43.9 million overall HAE drug spend in Prime's commercial book of business. Half of all HAE drug expenditures were billed through the pharmacy benefit and half through the medical benefit.

"Because HAE drugs are processed on both the medical and pharmacy benefit, it's essential to have integrated medical and pharmacy claims data to clearly understand patterns of use and comprehensively manage these members," said Catherine Starner, PharmD, BCPS, health outcomes consultant senior principal, Prime Therapeutics. "With drug costs driving 97 percent of HAE treatment expenses, we do not believe medical costs can be lowered through use of HAE drugs. Rather, diligent pharmacist case management following a patient's first use of HAE drugs must be provided to help ensure appropriate use and realize cost savings regardless of which benefit (medical or pharmacy) the HAE drug is billed."

Prime provides analyses of integrated medical and pharmacy claims data to help clients evaluate and enhance their HAE management programs. Prime deploys utilization management strategies, following set criteria for medical review and pharmacy prior authorization to ensure members are receiving the most appropriate treatment.

Keywords for this news article include: Pharmaceutical Companies, Business, Urticaria, Managed Care, Hypersensitivity, Prime Therapeutics, Angioneurotic Edema, Drugs and Therapies, Health and Medicine, Hereditary Angioedemas, Genetic Diseases and Conditions, Immune System Diseases and Conditions, Vascular Skin Diseases and Conditions.