Radar on Specialty Pharmacy

BCS Financial Corp. unveiled the Gene Therapy Rider on its EssentialCare Critical Illness insurance policy, the company said on June 18. The offering by the insurance and financial services company, which is owned by all 34 Blues plans, can pay the entire policy face value amount when a beneficiary is diagnosed with a covered disease and chooses to undergo treatment with an FDA-approved gene therapy. “The payments, which are based on the policy's face value, are made directly to the insured to use how they see fit,” says the company.

Prime Therapeutics LLC and Magellan Rx Management launched the technology-enabled specialty pharmacy solution Pharmacy Match, the companies said June 19. The offering, which is powered by Free Market Health’s cloud-based technology platform, is designed to drive competition by comparing prices across the market for specialty drugs and identifying the specialty pharmacy “best suited to meet their needs.” It also tracks each claim through fulfillment.

The FDA recently approved the second gene therapy for hemophilia B, Pfizer Inc.’s Beqvez (fidanacogene elaparvovec-dzkt). While the agent offers an additional treatment option with the potential for freedom from regular infusions of factor therapy, its price — which is equal to that of its competitor — may be too high for many payers, according to a Zitter Insights survey. Industry experts say that it may suffer from some of the challenges other cell and gene therapies have faced in gaining a foothold in the U.S. market.

On April 25, the FDA approved Beqvez for the treatment of adults with moderate to severe hemophilia B who use factor IX prophylaxis therapy; have current or historical life-threatening hemorrhage; or have repeated, serious spontaneous bleeding episodes and do not have neutralizing antibodies to adeno-associated virus (AAV) serotype Rh74var (AAVRh74var) capsid as detected by an FDA-approved test. The manufacturer launched a warranty program for the intravenous infusion based on durability of patient response to treatment.

Specialty drugs are still taken by only a small percentage of people but represent more than half of total drug costs. Anti-inflammatory specialty therapies continue to be a huge driver of those costs, according to the recently released 2023 Drug Trend Report from PBM analytics firm Xevant. The specialty pipeline remains strong, and payers should expect these agents to continue to affect their costs, says one industry expert.

Based on Xevant’s book of business for 2022 and 2023, the company observed an 11% increase in the number of prescriptions filled for specialty drugs. The plan-paid amounts for those agents rose 19%, slightly less than nonspecialty medications’ 22% plan-paid costs. In addition, the average plan cost per specialty prescription rose from $6,100 in 2022 to $6,700 in 2023.

While home infusion has been an option for patients for decades, the space continues to evolve. Within this landscape, providers must successfully execute the contracting process with PBMs and government and commercial insurers, navigating various pitfalls along the way.

Attorney Jesse Dresser, a partner in law firm Frier Levitt’s life sciences department who heads the firm’s pharmacy practice group and frequently helps pharmacies and pharmacy providers on issues with payers and PBMs, moderated a panel discussion titled “Strategies for Successful Payer and PBM Contracts in Home Infusion” at the National Home Infusion Association’s (NHIA) annual conference, held March 23 through 27 in Austin, Texas.

Data from two clinical studies found that people with inflammatory bowel disease — ulcerative colitis and Crohn’s disease — who were enrolled in one company’s IBD-focused digital care coordination program experienced decreases in both emergency department (ED) visits and hospitalizations compared with control groups. The data, says the company’s CEO, show the benefits of partnerships among stakeholders to manage chronic gastrointestinal (GI) care.

Established in 2018, SonarMD, Inc. enters into risk-bearing value-based care arrangements with health plans and gastroenterology practices. It currently has five such arrangements with large plans and partners with hundreds of U.S. gastroenterologists.