Commercial Specialty Trend
While specialty accounts for more than 51% of spend after rebates, it represents just over 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 launches of generics and releases of biosimilars in 2023 helped drive a noticeable negative unit cost trend. Oncology saw a 30% generic utilization rate and multiple sclerosis saw 60%+.
Targeted Immunomodulators (TIMs)
TIMs treat a wide variety of immunologic and inflammatory conditions. As in previous years, the TIMs class was the largest contributor to specialty medication costs in 2023, and overall utilization increased by nearly 9%. In 2023, multiple adalimumab biosimilars were released in direct competition with one of the top-selling drugs worldwide and the most utilized medication in the category - Humira®.
Aligned with our lowest-net-cost formulary management philosophy and after careful clinical consideration, Navitus added several adalimumab biosimilars to our formularies. Total cost of these products was reduced by 20% due to savings from biosimilar utilization and Humira® rebate enhancements that were fully passed through to clients. This decrease in unit cost helped offset the growth of other brand products, and led to an overall decrease in spend of –1.4% for the class.
Oncology
2023 saw an overall net cost growth of 11%, amid a 12% increase in members utilizing a specialty oncology medication. 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 in the second half of 2022 and first quarter of 2023, respectively. As a result, there was nearly a 20% decrease in overall cost across the category and generic utilization exceeded 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 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.
