Author: Amy Beal, PharmD – Pharmacy Services Director

 

 

Case Study: Agility is crucial for Pharmacy Benefits Managers (PBMs) in 2023.

Having an agile benefit provider is a key to business growth and profitability, since a PBM needs to actively monitor the market and make quick decisions that benefit a company and its employees. When a PBM can’t quickly react to changing circumstances, it can leave companies and their employees paying more. Here’s one case study of how PBMs should be reacting to the Market in Q1 2023 as new Multiple Sclerosis (MS) drugs come to market.

Quick adoption of the latest (MS) generic mediations.

MS is a challenging disease to manage that has traditionally required treatment with high-cost medications. Effective (but expensive) brand-name medications that most PBMs covered on their formularies included: Aubagio ($8,450 for a month’s supply), Gilenya ($8,795 monthly), Tecfidera ($10,420 monthly). While these drugs have been covered by PBMs, due to their high cost, significant restrictions have been in place such as step therapy and prior authorization. These restrictions frequently meant that consumers who truly needed the medications had weeks or months of delays in accessing drugs that could help them as they jumped through restrictive hoops.

Recently, however, three new generics: dimethyl fumarate, fingolimod, and teriflunomide have come to market. These generics equal their brand-name MS counterparts in efficacy, while costing much less. Instead of costing nearly $10,000 for a month’s supply, these new generics can be had for less than $350 per month. The market changed and a good agile PBM should already be offering corresponding changes to their clients.

But in order to change, a client and its PBM must have and/or desire three things:

First, the necessary specialty drug supply chain. PBMs must actively pursue contracts with specialty pharmacies that have access to new drugs. This access needs to be nationwide and available to all members, no matter where they live. Having access to a specialty pharmacy or pharmacies that carry these new MS drugs in all 50 states is the first step in ensuring member access to new-to-market drugs. This access is especially important as supply-chain issues continue to plague many industries, including pharmaceuticals, and there are a limited number of pharmacies in the U.S. that carry specialty medications.

Second, a desire to change. Oftentimes, expensive brand-name drugs such as Aubagio, Gilenya, and Tecfidera come with big rebates. Many PBMs are reluctant to lose that rebate money and therefore keep expensive brand-name drugs covered, creating higher prices for consumers. A true desire to change would mean a PBM would stop covering Aubagio, Gilenya, and Tecfidera and replace them on their covered drug list (formulary) with dimethyl fumarate, fingolimod, and teriflunomide.

Third, agile benefit changes. If a PBM does desire to provide lower-cost drugs to its clients and members, it needs quick front-end decision making and speedy back-end claims processing updates to implement transformation. In the case of the new MS drugs, PBMs should provide special pricing to encourage their quick acceptance and allow for 90-day fills so consumers are further incentivized to adopt lower cost medications. Finally, PBMs should remove any barriers, such as step therapy or preauthorization, that were formerly in place for MS medications so that consumers who need symptom relief can have access as soon as possible.

How is Scripius positioned with new MS coverage?

We are encouraging our clients and plan payers to adopt the three-part strategy above. Scripius has an exclusive contract with the Intermountain Specialty Pharmacy to supply dimethyl fumarate, fingolimod, and teriflunomide via home delivery in all 50 states, for $50 per month member cost share. We are also offering them at a 90-day supply, and removed step-therapy and preauthorization requirements formerly in place for MS medications.

On our most popular formularies, we have removed Aubagio, Gilenya, and Tecfidera from coverage, so that consumers and prescribers are directed to the new, low-cost alternatives. Our position is that directing consumers to lower cost drugs is the right thing to do for those suffering with MS, while also potentially saving money for our clients and other payers.

For more about how Scripius works to provide agile improvements in a volatile market, visit us on LinkedIn or at scripius.org.