Utilization, cost trends, and member cost-share for self-injectable multiple sclerosis drugs--pharmacy and medical benefit spending from 2004 through 2007

• Published in: Journal of managed care pharmacy 2007-11, Vol.13 (9), p.799-806
• Main Authors: Kunze, April M, Gunderson, Brent W, Gleason, Patrick P, Heaton, Alan H H, Johnson, Steven V
• Format: Article
• Language: English
• Subjects: Antibodies, Monoclonal - economics; Antibodies, Monoclonal - therapeutic use; Antibodies, Monoclonal, Humanized; Brief Communication; Cost Sharing; Deductibles and Coinsurance - economics; Deductibles and Coinsurance - trends; Drug Costs - trends; Drug Utilization - economics; Drug Utilization - statistics & numerical data; Drug Utilization - trends; Fees, Pharmaceutical - statistics & numerical data; Fees, Pharmaceutical - trends; Glatiramer Acetate; Humans; Immunosuppressive Agents - economics; Immunosuppressive Agents - therapeutic use; Inflation, Economic; Infusions, Intravenous; Injections, Intravenous; Interferon Type I - economics; Interferon Type I - therapeutic use; Mitoxantrone - economics; Mitoxantrone - therapeutic use; Multiple Sclerosis - drug therapy; Multiple Sclerosis - economics; Natalizumab; Peptides - economics; Recombinant Proteins; Self Administration; United States
• ISSN: 1083-4087; 1944-706X
• DOI: 10.18553/jmcp.2007.13.9.799

In 1993, interferon beta-1b became the first of 4 self-injectable multiple sclerosis (MS) drugs to be approved by the U.S. Food and Drug Administration. Initially covered as a medical expense, self-injectable MS drugs are increasingly considered specialty pharmaceuticals and are often covered under the pharmacy benefit. Self-injectable MS drugs are expensive, costing approximately $2,000 per month per patient in 2007. To (1) determine the trends for price and utilization of self-injectable MS drugs, (2) meld medical and pharmacy claims data to capture total health care spending on self-injectable MS drugs, and (3) calculate the out-of-pocket cost-share for members with pharmacy benefits. A pharmacy benefits manager with integrated medical claims for approximately 1.8 million commercial members, about 20% of its total of 9 million commercial members, analyzed self-injectable MS pharmacy claims for a 45-month period beginning in January 2004 and ending in September 2007 and integrated medical and pharmacy claims for a 42-month period beginning in January 2004 and ending in June 2007. The 9 million members are beneficiaries of 10 Blue Cross Blue Shield (BCBS) health plans distributed throughout the United States, and the subset of 1.8 million members are enrolled in 1 BCBS health plan in the Northern Plains states. Self-injectable MS drugs were identified using Generic Product Identifier (GPI) codes for the National Drug Code (NDC) numbers on pharmacy claims. Mail order pharmacy claims with up to a 90-day supply were counted as 3 claims, and community pharmacy claims dispensed with up to a 34-day supply were counted as 1 claim. Self-injectable MS drugs were identified from medical claims using Healthcare Common Procedure Coding System (HCPCS) codes: J1595 for glatiramer, J1830 for subcutaneous interferon beta-1b, Q3026 for subcutaneous interferon beta-1a, and Q3025 and J1825 for intramuscular interferon beta-1a. For the approximately 9 million members with data from pharmacy claims only, these 4 self-injectable MS drugs accounted for approximately 1.8% of total pharmacy benefit spending in 2004, 1.9% in 2005, 2.3% in 2006, and 2.4% in 2007. The mean average wholesale price (AWP) per member per month (PMPM) increased by 56.8%, from $1.11 PMPM in the first quarter of 2004 to $1.74 PMPM in the third quarter of 2007. Utilization was flat at about 82-83 claims per 100,000 members per month during the 45-month measurement period. The average annual price increase p