Industry Voices—Reimagining cost management for autoimmune diseases

Specialty conditions—which account for 52% of pharmacy spend even though only 2.5% of members use them—continue to be a significant concern for payers seeking to offer sustainable prescription drug benefits while controlling costs. 

Within specialty, autoimmune conditions like psoriasis are a particularly high-impact therapeutic category.

Psoriasis causes increased skin cell production leading to raised, scaly patches that can itch, crack, and bleed, and affects about 8 million people in the U.S. Anyone with psoriasis will tell you that it is a challenging disease to manage—and it can be exceedingly expensive to treat.

Monthly costs for treatments can average upwards of $600 for topicals and annual biologic costs can range from between $40,000 and $50,000 (PDF), placing it among the top five conditions that drive drug spending.This has, in turn, made it a key area for pharmacy benefit managers like CVS Caremark that are focused on ensuring clinically appropriate utilization and access, while managing spend.

An evidence-based approach to navigating a constantly changing treatment landscape

The good news for people living with psoriasis is that there is a wide universe of treatments for them including topicals, biologics, oral medications, phototherapy and even complementary and integrative medicine.

But this wide range of options means that identifying the right kind of treatment can be a challenge and many patients may start on biologics when lower-cost treatments may be more effective. This can lead to wasted spend for both payers and their members.

The marketplace of treatments is constantly evolving, so PBMs must use their expertise to closely monitor pharmaceutical developments. With clinically rigorous criteria and management strategies, PBMs can ensure the most appropriate therapy is being used for each member based on their specific diagnosis and treatment guidelines.

Proven strategies bolstered by targeted, innovative solutions

For psoriasis, as with other therapeutic areas with a range of treatments available, most with high price tags, PBMs utilize a range of proven strategies including utilization management criteria. For instance, a commonly used treatment for psoriasis, Stelara, has multiple supplemental indications to treat a range of autoimmune conditions.

The FDA recommended dose for Stelara varies by the patient’s weight and by indication. Our analysis found up to 30% of members on Stelara are prescribed the medication at dosage exceeding the FDA’s recommendation. So, we incorporated indication and weight-based dosing limits directly into the prior authorization process.

By automating the approval process and ensuring the appropriate dose, we can improve member experience and safety while eliminating wasted spend for clients. This approach has led to an 8.4 percentage point reduction in high-dose Stelara and gross savings of $21 million.

Digital tools and targeted interventions can further help enhance safety, reduce waste and encourage positive behavior for better outcomes.

For instance, CVS Caremark has developed intelligent medication monitoring that uses advanced analytics to identify when patients may no longer benefit from their treatment—tracking efficacy, symptoms, pain and exacerbations.

With this information, we can use our high level of digital engagement with members to send them targeted messages through a channel of their preference. When appropriate, we can work with providers to deliver targeted interventions, including stopping treatment or changing to a different therapy. Other tools like supply management optimization can help ensure members have the right amount of medication on hand without running out or inadvertently accumulating oversupply, as even a small amount of excess can add costs across populations given the high price of specialty therapies.

Embracing cost-saving innovations in the treatment landscape

A PBM can also help identify novel, lower-cost therapies and encourage their use. UV phototherapy, which uses rays like those found in natural sunlight to slow the growth of affected skin cells is an economical and convenient treatment option that has proven to be effective for many people with psoriasis as well as other skin conditions like vitiligo or eczema.

UV phototherapy costs about $5,000 for three years of effective treatment compared to some biologics that cost that much each month. Despite this, many people living with psoriasis don’t have access to UV phototherapy.

We recently launched a pilot that offers CVS Caremark members at-home phototherapy treatment via an app-controlled, connected UV device, along with high-touch support services to support adherence and optimize the experience. The aim is to help members more conveniently and effectively manage their condition with alternative therapy, and delay, decrease or discontinue the use of biologics. 

PBMs like CVS Caremark seek to continuously innovate to help payers stay ahead of marketplace trends and can be an invaluable partner in the quest to aggressively manage specialty costs, while ensuring that patients with complex diseases like psoriasis receive the support they need.

Prem Shah is the executive vice president of specialty pharmacy at CVS Health.