Commercial Specialty Trend
While specialty accounts for more than 51% of spend after rebates, it represents just more than 1% of all prescriptions filled for Navitus commercial clients. These percentages are in line with national numbers, where more than $300 billion is spent in the United States each year across this category.¹
Health plans, sponsors and consultants must be able to access data that comprehensively tracks where money and resources are allocated. True transparency means they get this access, empowering them to make impactful decisions. We bolster this transparency with an emphasis on service excellence in a people-first environment.
$51.97
Net Total Cost Per Member Per Month (PMPM) for Commercial Clients in 2023
Lower Cost Alternatives Lessen Specialty Cost Trends
The availability and utilization of new generics and biosimilars in 2023 drove a negative cost trend in specialty. Generic utilization rates of 30% and 60% were seen within oncology and multiple sclerosis, respectively.
In addition, 85% of specialty claims were filled through Lumicera Health Services, our specialty pharmacy. For clients and members utilizing, they benefit from its unique cost-plus model.
Targeted Immunomodulators (TIMs)
TIMs treat a wide variety of immunologic and inflammatory conditions such as rheumatoid arthritis, psoriatic arthritis, Crohn’s Disease and ulcerative colitis. As in previous years, the TIMs class was the largest driver of specialty medication costs, and the most utilized medication was the biologic Humira (adalimumab). In 2023, multiple adalimumab biosimilars were released, marking the first time the industry experienced direct competition to one of the most lucrative drugs in the world
Overall utilization in TIMs increased by nearly 9% in 2023, driven in part by the rising popularity of brand biologics – medications derived from biological sources and generally delivered via injection or infusion.
Total cost of these products was reduced by 20% due to savings from biosimilar utilization and Humira rebate enhancements fully passed through to clients. However, increased utilization of Stelara ultimately soften savings across the whole category to a year-over-year trend of just -1.4%.
Oncology
Overall net cost growth of 11% was seen in 2023, with utilization increasing 12% over 2022. A high rate of generic utilization at 30% helped offset some of this spend growth.
Multiple Sclerosis (MS)
Generic options for Gilenya® (fingolimod) and Aubagio® (teriflunomide) launched the second half of 2022 and first quarter of 2023 respectively, resulting in a nearly 20% decrease in overall cost across the category.
With these launches, generic utilization within the MS category now exceeds 60%.
Lumicera helped control cost across the category with significantly lower spend on generics and bolstered this with a people-first approach.
High-Cost Claims
High-cost claims have become the fastest-growing healthcare cost for employers in the United States over the last 10 years, and many plan sponsors increasingly see claims in the millions of dollars for a single covered member.²
In 2023, 13 products had an average cost above $50,000. With just 85 members in the dataset using these products, the result was still nearly $30 million in spend. This is approximately the same cost as medication therapy for 400,000 members with high blood pressure.
EpiphanyRx, our in-house solution for employer groups of 3000 lives or fewer, implemented our QALYiQ™ program that specifically identifies untapped savings opportunities for high-cost claims. Doing so helped one company save nearly $200,000 in 2023 and their member to stay on needed prescription therapy.
