By Amy Beal, Pharmacy Services Director
Plan sponsors seeking lowest net-cost prescription management need a comprehensive approach that is continually adapting to changing market dynamics. Scripius has a team of pharmacists who are tuned into prescription pipelines for all disease states and complete comprehensive reviews each year. In 2024 this team analyzed the entire diabetes and arthritis portfolios to produce cost-saving strategies for commercial plan sponsors. The results of the team’s Quarter 1 and 2 clinical management strategies started for most clients in October 2024, with further savings expected for 2025.
While hot topics get the headlines, PBMs need comprehensive campaigns.
Five years ago, the high cost of insulin was the hot topic in diabetes care. The cost of insulin rose 54% from January 2014 to April 2019[1]. With the help of public and political pressure, healthcare and health insurance systems acted. Insulin prices dropped 10% from January 2020 to July 2023 with large insulin manufacturers pledging to cap monthly insulin costs at $35 per month for their most common insulin products[2]. Today most patients are able to obtain reasonably affordable insulin.
But most people with diabetes are not treated with insulin. Action needs to be taken to reduce the cost of all diabetes treatments. Over the past several years, Glucagon-like peptide-1 receptor agonists (GLP-1s) have replaced insulin as the hot topic in diabetes treatment. High prices and soaring usage rates (GLP-1 utilization increased by 700% from 2019 to 2023[3] and a one month’s supply exceeds $1,000[4]) mean Pharmacy Benefit Managers (PBMs) should already have defined GLP-1 strategies. Read about the Scripius GLP-1 strategy that has been in place since 2020 here.
At the same time, insulin and GLP-1 strategies do not create a comprehensive approach to all diabetes therapies. There remains plenty of meat on the cost-savings bone in other diabetic drug classes. To that end, it is important for a PBM’s clinical pharmacy team to see beyond the hot topics of diabetes care.
Instead of having hot-topic tunnel vision, PBMs should be forecasting to achieve future cost saving opportunities.
There are important diabetes management steps PBMs should take now outside of the GLP-1 arena. Scripius has responded to changes in the Sodium-glucose cotransporter-2 (SGLT2) and Dipeptidyl peptidase-4 (DPP-4) market. The Scripius team developed key cost savings solutions that will benefit most commercial clients and their members starting as early as October 1, 2024[5]. There are key changes where we expect to achieve significant cost savings.
- Removing Jardiance (and its combination products) from commercial formularies and adding Brenzavvy (bexagliflozin) will create a lower-net cost. Jardiance (empaglivlozin) and Farxiga (dapagliflozin) are both SGLT-2s with proven efficacy in reducing kidney and heart failure outcomes. Working with thought leaders in diabetes, Scripius made the decision that only one of these products needed coverage and removed Jardiance from commercial formularies effective October 1, 2024. Brenzavvy was added in response to requests for an SGLT-2 with a lower out-of-pocket cost for members. While Jardiance and Brenzavvy are both SGLT-2 inhibitors with similar efficacy in lowering blood glucose and A1c, these two medications are very different in the marketplace. Jardiance has a huge advertising budget and a large sales staff providing samples for prescribers to distribute. Brenzavvy, in contrast, has little marketing or sales efforts. One result of this disparity is that Jardiance costs about $550 for a month’s supply while Brenzavvy costs about $55 per month. One key that allowed Scripius to make this coverage change has been reliable access to Brenzavvy. Our members and health plans can use insurance benefits to access low-cost Brenzavvy through Mark Cuban Cost Plus Drugs and through the Intermountain Home Delivery Pharmacy.
- Farxiga will remain as a covered drug option in anticipation of less-expensive dapagliflozin generics coming to market in 2025.
- While DPP-4s have a smaller market share than SGLT-2 inhibitors, many people with diabetes rely on them to help control their blood sugar. Scripius removed another expensive DPP-4 branded product, Tradjenta ($560 per month), from our commercial formularies beginning October 1, 2024 and we are encouraging members to seek less expensive, covered generic alternatives which include alogliptin and saxagliptin with a monthly cost of less than $200.
The goal is to help members access lower cost alternatives now, while removing unneeded, higher cost medications from coverage. With cardiovascular and kidney outcomes data, it’s important to Scripius that our members can have Farxiga covered. However, when the multi-source generic dapagliflozin hits the market in 2025, it will be easy for these members to transition and create the lowest-net cost pricing for both members and our plan sponsors. Ultimately, in 2026, we envision most members, who take drugs in the SGLT-2 class to be using Brenzavvy or a Farxiga generic. This strategy should produce real savings.
Resisting hot-topic tunnel vision means examining all disease state opportunities.
Just as it is important to resist the temptation to have tunnel vision around GLP-1 utilization, it is similarly important to look for savings opportunities outside of the diabetes class. The biosimilar market has great savings opportunities for a pair of expensive and highly used arthritis therapies. Scripius has a proven track record of being aggressive in biosimilar adoption. Read more about our biosimilar strategy here.
- Beginning October 1, 2024 we removed coverage of Humira from most of our commercial health plan formularies and transitioned members to adalimumab biosimilar therapies. Adalimumab biosimilars—Amjevita (adalimumab-atto) and Hadlima (adalimumab-bwwd)—have a lower net-cost[6] [7] than Humira and this change will create savings for both plan sponsors and members.
- Actemra (tocilizumab) is a biologic used to treat several rheumatologic conditions. Scripius has worked with clinical healthcare partners that administer intravenous arthritis medications at their facilities. As part of this collaboration, we will be transitioning most of our members away from Actemra to a less-expensive biosimilar therapy[8].
Transparent data is the proof in the pudding.
At Scripius we are excited to track how our clinical management impacts actual lowest net costs for members and plan sponsors. Many PBMs promise low net-cost prescription management, but what they often deliver is padding to their bottom line with no way for health plans to verify savings.
We will monitor savings and report transparent data to plan sponsors and consumers about the clinical changes we’ve made. Reportable data will be available in the first quarter of 2025, and we look forward to future savings that will take effect next year due to our forecasting actions today.
Want to talk about making the switch to Scripius? Email MaketheSwitch@Scripius.org
Scripius may refer to the drugs or pharmacies in this letter by their respective trademarks, but Scripius does not own those trademarks; the manufacturer or supplier owns the trademark. By listing drugs or pharmacies, Scripius does not endorse or sponsor any drug, manufacturer, or supplier. These manufacturers and suppliers do not endorse or sponsor any Scripius service or plan and are not affiliated with Scripius.
[1] https://www.goodrx.com/healthcare-access/research/how-much-does-insulin-cost-compare-brands
[2] https://www.goodrx.com/healthcare-access/research/how-much-does-insulin-cost-compare-brands
[3] https://www.bmj.com/content/386/bmj.q1645#:~:text=The%20paper%2C%20published%20in%20Annals,205%20109%20to%20459%20278.
[4] https://www.truveta.com/blog/research/monitoring-glp-1-prescriptions-march-2024/#:~:text=Overall%20prescribing%20rates%20(GLP%2D1,2024%20compared%20to%20December%202023).
[5] Some plans may not experience changes until January 1, 2025 or at next renewal.
[6] https://www.managedhealthcareexecutive.com/view/kaiser-permanente-expects-to-save-300-million-switching-to-amjevita
[7] https://organonpro.com/en-us/product/hadlima/affordability/#:~:text=Based%20on%20comparison%20of%20Wholesale,source%20product%20pricing%20for%20HUMIRA.
[8] https://www.drugs.com/compare/actemra-vs-tyenne