PBM: Specialty Medications Drive Increased US Prescription Drug Spending

The number of people who had annual prescription medication costs of $50,000 or more in 2016 was 35% higher than it was in 2014, according to pharmacy benefit manager Express Scripts.
Jackie Syrop
October 04, 2017
The number of people who had annual prescription medication costs of $50,000 or more in 2016 was 35% higher than it was in 2014, according to pharmacy benefit manager (PBM) Express Scripts.

The company’s new report, Super Spending: US Trends in High-Cost Medication Use, indicates that nearly 0.3% of Express Scripts members had annual medication costs at or greater than $50,000 in 2016. While 0.3% seems like a very small population, the company notes, it accounted for 21.3% of total pharmacy costs. “Extrapolating these data to the US population, an estimated 870,000 Americans accounted for $80 billion of the 2016 US pharmacy spend.”

Among those with $50,000 or more in prescription drug costs in 2016, more than 25% of costs were for oncology drugs, followed by drugs to treat multiple sclerosis (MS), inflammatory conditions, and hepatitis C. The report notes that all of the top therapy classes are for specialty medications, except for pain and inflammation. Specialty drugs include injectables (such as biologics and biosimilars) and non-injectable drugs typically used to treat chronic, complex conditions. Specialty drugs usually require 1 or more of the following:
  • Frequent dosing adjustments or clinical monitoring
  • Intensive patient training and compliance assistance
  • Limited distribution
  • Specialized handling or administration
The report reveals a significant shift in what drives spending among Americans with high annual pharmacy costs. Whereas in 2014, compounded medications and new hepatitis C therapies drove much of the spending among patients with $50,000 or more in annual pharmacy costs, in 2016, treatments for cancer, MS, inflammatory cystic fibrosis (CF), and other complex and rare diseases were the prominent drugs used in the high-cost population. The hepatitis C therapies and compounded medications that drove high costs in 2014 “virtually disappeared” from use in the 2016 report, replaced by safer and lower-cost alternatives, the company said.

The Express Scripts report was based on data gathered from anonymized prescription claims from 134,000 patients with high annual pharmacy costs among a group of 26 million Americans covered by commercial insurance, Medicare, Medicaid, or health exchanges. The analysis accounted for drug manufacturer rebates and foundation grants.
Among the group of patients whose costs met or exceeded $50,000 annually, the percentage of costs were for treatments for the following: 
  • Cancer, 25.6%
  • MS, 18.3%
  • Inflammatory conditions, 11.6%
  • Hepatitis C, 10.6%
  • Pulmonary hypertension, 3.0%
  • CF, 2.9%
  • Hereditary angioedema, HIV, sleep disorders, and pain/inflammation, 28%
The report broke down data by plan, age, region, and out of pocket (OOP) costs for patients who had $50,000 or more per year in drug costs:

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