Amid rising drug costs, employers and payers should be keeping a closer eye on products in the pipeline as they design formularies.
Specifically, there are certain emerging therapies that could lead to significant costs down the road, according to Optum, which recently released its list of five drugs to watch in 2019.
Those drugs are:
- Golodirsen, a treatment for Duchenne muscular dystrophy
- Siponimod, which aims to delay the progression of multiple sclerosis
- Zynquista, or sotagliflozin, a new oral insulin adjunct medication for people with Type 1 diabetes
- Risankizumab, an injectable medication for plaque psoriasis
- Ultomiris, a longer-lasting medication for paroxysmal nocturnal hemoglobinuria, a rare blood disorder
David Calabrese, OptumRx vice president and chief pharmacy officer, told FierceHealthcare that drugs like these, particularly those for rare diseases, have been consistent cost drivers. He said it’s crucial for insurers to be watching these products early, so those with limited value can be determined sooner.
“I think it’s just exercising a heightened level of due diligence,” he said. “Historically, organizations like ours would wait until the product was FDA approved, then dive into the data. We’ve taken a much more proactive approach over the course of the last half decade or so.”
Optum projects spending several years out in its analysis. For example, sales of Zynquista and other sotagliflozin products could peak at $1.3 billion by 2024, according to the report. That drug did hit a snag with the Food and Drug Administration, however, which declined to approve it in March, likely delaying a 2019 launch.
Golodirsen is in development by Sarepta Therapeutics, which also currently offers a similar product in that class, Exondys-51, priced at $300,000 per year—so Optum expects Golodirsen to be similarly costly.
Aside from greater awareness, what can payers do to better manage the costs of expensive new therapies? Alongside monitoring emerging therapies and treatments for rare conditions earlier, Optum has developed clear guidelines for physicians, so they know when it’s appropriate to provide these pricey drugs to patients, Calabrese said.
It does this using a digital tool called PreCheck MyScript, which notifies doctors within the electronic health record of their options for certain conditions, what a patient’s out-of-pocket costs would be and if a prior authorization is required. Physicians then have the option to apply immediately within in the system for prior authorization if they choose that drug, Calabrese said.
“They’d know immediately whether that product would be approved or not for that given patient at that given time,” Calabrese said.
In addition, Optum recommends that payers offer a robust list of biosimilars to ensure that patients have access to lower-cost alternatives to pricey brand drugs. While this is a challenge, as the biosimilar pipeline is limited at present, Calabrese said one of the key functions of its specialty pharmacy is to make patients and doctors more aware of these alternatives.
It's also key to closely monitor drugs like those on Optum’s list for effectiveness and any potential negative side effects after offering coverage, so that they’re included in formularies where it makes the most sense, he said.