Ninth annual report features a comprehensive view of medical pharmacy trends in claims data, including all major lines of business
Trends Highlight the Need for More Effective Management Strategies
Commercial per-member-per-month (PMPM) medical drug spend increased 18 percent to
“The data shows that the trend over the last five years for
Site of service continues to be a concern, with drugs administered in the hospital outpatient setting continuing to cost 2-3 times more than physician offices and home infusion sites of service. Sixty-eight percent of payers are now using a site of service program.
Forecasting Significant Medical Benefit Categories
The report illustrates that over the last 12 months there were significant changes to many provider-administered therapeutic categories covered on the medical benefit. Novel oncology therapies and immunotherapy treatments continued to drive the highest spend. Antihemophilic factor is the category with the highest annual trend increase at 62 percent in Commercial and 185 percent in
According to the report, oncology had the highest PMPM spend across all lines of business (LOB), with Rituxan, Herceptin and Avastin remaining in the top five drugs for Commercial plans along with Opdivo in the top 10. By 2022, chimeric antigen receptor T-cell therapies (CAR-T) for oncology immunotherapy treatment are projected to have an increase in PMPM spend of 581 percent.
Programmed-cell death (PD)-1 inhibitor Keytruda (pembrolizumab) had an impactful increase in utilization with at least a 200 percent increase in PMPM spend in each LOB, vaulting Keytruda into the top 15 drugs. Opdivo (nivolumab), another PD-1, lost market share to Keytruda but still accounted for 56 percent of commercial oncology checkpoint inhibitors.
First Look at Medicaid Medical Pharmacy Analysis
Notably, 14 percent of
Review of Biosimilar Reimbursement Strategies
In a large swing from previous years, more than half of payers (51 percent) required members to step through a biosimilar before utilizing its reference product; of those payers who do not have one in place, 41 percent were not planning to implement a step at all. Looking ahead, 64 percent of payers indicated that the pricing of biosimilars was most impactful on their reimbursement decisions with the anticipation that three of the top spend oncology agents could have biosimilars on the market in 2019.
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Magellan Rx Management is a full-service, next-generation pharmacy benefit manager (PBM) that helps our customers and members solve complex pharmacy challenges by connecting them to the people, technology, and information they need to make smarter healthcare decisions. As experts in managing specialty spend both on the prescription and medical benefit, we are energized by discovering new and better ways to deliver solutions in today’s complex and rapidly-evolving healthcare environment, leading people to live healthier, more vibrant lives. Magellan Rx Management is a division of
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