Autoimmune Disorders (High-Cost Biologics) | Physician & Payer Forum | US | 2015

How Are Payers Reacting to Elevated Costs and How Will the Cost Trend Impact Specific Brands?
The nation’s healthcare payers are using multilayered cost and utilization control strategies to rein in the double-digit growth in their costs for biologics and other high-priced specialty therapies, with specialty drugs expected to consume half of the drug spend by 2018. Among the areas of greatest concern is the autoimmune disease category (especially rheumatoid arthritis [RA]), considered the highest-cost disease category in the U.S. (according to the pharmacy benefit management industry) and the one for which cost trend is expected to accelerate the most, next to oncology.

U.S. managed care organizations (MCOs) have adopted multiple cost-control strategies on every front: prescribing is addressed by prior authorization and step therapy protocols; utilization is affected by increased member cost sharing; and infusion costs are reined in by site-of-care restrictions. The use of specialty and mail-order pharmacies offers better control through tracking, reporting, and management of drugs.

A variety of therapy options exist for the treatment of the autoimmune conditions RA, psoriatic arthritis (PsA), and systemic lupus erythematosus (SLE). Typically in the case of RA and PsA, conventional disease-modifying antirheumatic drugs (DMARDs) are prescribed first, and the wide availability of generic products in the class helps hold down costs for payers and patients. For patients who do not respond to those treatments, the highly effective newer biologic versions of DMARDs, including the frequently prescribed tumor necrosis factor-alpha (TNF-α) inhibitors (i.e., Amgen/Pfizer’s Enbrel [etanercept], AbbVie’s Humira [adalimumab], and Janssen/Biotech’s Remicade [infliximab]), offer patients a chance to get relief and resume life’s activities. These and other later-line and emerging therapies—including some of the first biosimilars to come to the U.S. marketplace—will create more cost pressures for managed care companies but also will set the stage for competitive contracting and preferred drug tiering, a key strategy in holding down costs. For SLE, GlaxoSmithKline’s Benlysta (belimumab) is the first drug approved for SLE in more than 50 years and is the first biologic approved for the indication. However, uptake of Benlysta has been tempered by its relatively high price in a largely generic market coupled with physicians’ perception of its modest efficacy, slow onset of action, and inability to be used in patients with severe, life-threatening organ involvement.

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