Prime Study: Spending on Chemotherapy Drugs is a Leading Driver of Drug Costs

Almost half of members spending more than $50,000 per year on drug costs were being treated with chemotherapy.

Almost half of members spending more than $50,000 per year on drug costs were being treated with chemotherapy.

Chemotherapy treatment for cancer is the top cost driver among high-cost pharmacy and medical benefit plan members, according to a new study presented by pharmacy benefit manager Prime Therapeutics LLC (Prime). Prime will be presenting the study at the Academy of Managed Care Pharmacy (AMCP)’s Nexus 2013 conference in San Antonio on Oct. 17, 2013.

High-cost members — those spending $50,000 per year or more on pharmaceuticals under either their pharmacy or medical benefit – are rare, making up just 18 per 10,000 members. But medication spending among these members accounts for more than 17% of total drug costs.

Prime’s analysis of more than 7.8 million continuously enrolled members in 11 different health plans in 2012 found 45.6% of high-cost members received chemotherapy. Total drug spending among all members was $8.2 billion (19.3% from the medical benefit and 80.7% from the pharmacy benefit). High-cost members receiving chemotherapy accounted for $516 million (36.9%) of the $1.4 billion high-cost member drug spending. Top cancer categories included breast, colorectal, non-Hodgkin’s lymphoma and lung cancer. About two-thirds (62.3%) of these chemotherapy receiving members’ drug costs were covered under the medical benefit, with the rest of the costs covered under the pharmacy benefit.

“Cancer care is a top cost driver and there are a number of new cancer treatments in clinical trials today. Understanding spending among these members is complicated by the fact that treatments are covered by both the medical and pharmacy benefit, and treatment regimens often involve multiple chemotherapy agents, plus additional drug therapies,” said Pat Gleason, PharmD, BCPS, FCCP, director of health outcomes for Prime.

Identifying the factors driving pharmacy costs under both the medical and pharmacy benefit will assist health plans and plan sponsors better manage care through evidence-based treatment algorithms, drug distribution channels, contracting activities, and care coordination, Gleason said.

About Prime Therapeutics

Prime Therapeutics LLC (Prime) helps people get the medicine they need to feel better and live well. Prime manages pharmacy benefits for health plans, employers, and government programs including Medicare and Medicaid. The company processes claims and delivers medicine to members, offering clinical services for people with complex medical conditions. Headquartered in St. Paul, Minn., Prime serves nearly 23 million people. It is collectively owned by 13 Blue Cross and Blue Shield Plans, subsidiaries or affiliates of those plans. Prime has been recognized as one of the fastest-growing private companies in the nation.


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