New Cystic Fibrosis Treatments May Significantly Increase Pharmacy Benefit Costs

ST. PAUL, Minn., April 6, 2015 /PRNewswire/ -- Ground-breaking new cystic fibrosis treatments, that target the gene mutations causing the disease, will significantly increase health care costs. This is the finding of new research by pharmacy benefit manager Prime Therapeutics LLC (Prime). Researchers from Prime will present the study at the Academy of Managed Care Pharmacy (AMCP) 27^th Annual Meeting and Expo in San Diego April 7-10, 2015.

Cystic fibrosis is a genetic disease affecting multiple organ systems, most importantly the lungs and airways. An estimated 30,000 children and adults in the United States have the disease, which can lead to life-threatening lung infections and the inability to absorb nutrients from food. Some individuals may need a lung transplant because of progressive damage to the lungs. 

In 2012, the first treatment to target a specific gene mutation, ivacaftor (Kalydeco®), received U.S. Food and Drug Administration (FDA) approval. Ivacaftor treats a type of gene mutation found in about 4 percent of people with cystic fibrosis and costs $300,000 per year. A new combination drug – ivacaftor plus lumacaftor – is pending FDA approval for treatment of people age 12 and older who have the gene mutation found in nearly 50 percent of people with cystic fibrosis. The price of the new drug is not yet public, but is widely expected to be similar to ivacaftor's price.

"Genetic research is helping advance new treatments that target not just the symptoms of disease, but the actual genetic causes," said Kevin Bowen, MD, MBA, principal health outcomes researcher at Prime. "But these new treatments are coming with a steep price tag, as people with cystic fibrosis will take these drugs for several decades. Nationally, it could cost our health system as much as $4.5 billion per year to treat up to 15,000 people with cystic fibrosis who could benefit from this new combination drug. People with cystic fibrosis, their health plans and especially self-insured employers, must prepare now to manage the significant costs associated with these new treatments."

According to Prime's analysis of more than 13 million commercially insured members, the mean total medical and pharmacy cost for individuals using ivacaftor is more than $367,000 per year. If a person with cystic fibrosis continued to take ivacaftor for 28 years (40 years is the approximate life expectancy) they would accumulate $8 million in drug costs alone. For those people with cystic fibrosis who received a lung transplant, total medical plus pharmacy costs in the year of transplant averaged nearly $577,000, while annual costs averaged $143,000 per year following transplant. Members who had not received a lung transplant and were not being treated with ivacaftor had total medical and pharmacy costs that averaged about $76,000 per year.

Prime's analysis found 3.7 percent of its members with cystic fibrosis who were six years old and older were taking ivacaftor. The new combination drug would treat people age 12 or older. Further analysis found the prevalence of cystic fibrosis among Prime's commercial members age 12 and older was 9.6 per 100,000. Based on these results, an estimated 4.5 per 100,000 members would meet criteria for the new combination drug when it becomes available. Prime researchers estimated that 90 percent of these members would receive the new drug, at an anticipated cost of $300,000 per year (similar to ivacaftor). This would result in an increase of about $1 per member per month in pharmacy costs, or approximately $150 million per year in new costs.

The number of individuals who are likely to be treated with the new drug is expected to vary between different populations because prevalence of cystic fibrosis varies greatly by race and ethnicity. For example, cystic fibrosis is 5 to 6 times more common in Caucasian than African American or Hispanic populations.

Bottom line, even if this new treatment could erase all medical costs for these people with cystic fibrosis, which is not possible, the cost of the drugs alone would result in a very large increase in the cost of treating cystic fibrosis.

Prime deploys utilization management strategies such as prior authorization and quantity limits, and care management strategies such as nursing assessments through Prime Therapeutics Specialty Pharmacy LLC, to best help manage care and costs for cystic fibrosis members.

Visit primetherapeutics.com to read more about the study.

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 more than 26 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.

For more information, visit www.primetherapeutics.com or follow @Prime_PBM on Twitter.  

SOURCE Prime Therapeutics LLC

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