Excellus BCBS Broker News Vol. 19 No. 8 Special Issue | CareValue Agent Blog (2024)

A Message from Mona Chitre

As we look to the rest of the 2024 plan year, I wanted to take a moment to share all that has been happening in the pharmacy space and reiterate our mission to provide greater access to high-quality health care. As supporters of your business and clients, we continuously monitor and evaluate market information to make sure we are tailoring our programs and developing innovative solutions to meet their needs.

Below are highlights of our pharmacy updates this year and links to additional articles to provide you more information.

2024 Pharmacy Updates

• Biosimilars:To date, there have been 57 biosimilar approvals and 38 launches in the U.S. market¹ , which is good news for groups and members. As new biosimilars enter the market, increased competition brings down the price of the biosimilar and reference product. We continually monitor these drugs for formulary optimization so we can promote the use of biosimilars when the overall net cost is lower than its biologic product. Our approach to biosimilars differs by drug or drug category. In some drug categories like oncology, we take a biosimilar-first approach and as a result of this, adoption of the biosimilars for Avastin®, Herceptin® and Rituxan® reached 75% of the market share within two years of launch and we have generated $30 million in savings for our customers. For other categories where the marketplace dynamics are more complex, we currently provide access to the biosimilars while still maintaining coverage of the innovator brand product. Along with our formulary strategy, our Value Based Payment (VBP) arrangements with our local health systems allow us to work collaboratively to encourage switching to biosimilars when appropriate.
• Gene and Cell Therapy:Gene and cell therapy offer innovative treatment options for members but can present financial challenges for groups. The US cell and gene therapy market was valued at $3.22 billion in 2022 and is projected to reach $25.58 billion in 2028^A . Knowing how rapidly these trends are increasing we are always looking for ways to ensure better cost management. At Excellus BCBS we uniquely manage each gene and cell therapy case by developing prior authorization criteria. Our policy development team assesses the therapy for medical necessity overall evaluating the drug's clinical efficacy, safety profile, and cost-effectiveness compared to alternative treatments. This creates balance between patient access and cost management.
• Glucagon-Like Peptide-1 Agonists (GLP-1): Blue Health Intelligence® released new key findings on GLP-1 use for weight management. The data showed that 30% of patients stopped treatment within four weeks, before reaching the targeted dose³. This data further supports our Utilization Management efforts to provide an unbiased review for each request of a GLP-1 to confirm medical necessity and safety – protecting against inappropriate prescribing and wasteful spending. Currently, we are saving groups an average of $2.66 PMPM* through GLP-1 Utilization Management.
• Medication Assurance Program**: Drugs approved via the Food and Drug Administration’s (FDA) Accelerated Approval pathway are often very expensive specialty medications. Unlike traditional FDA approved drugs, Accelerated Approval drugs have indications that have unconfirmed clinical benefit at the time of their approval. In response to this unique approval process, we have created the Medication Assurance program. This first-of-its-kind program is designed to ensure effectiveness and reduce spend of Accelerated Approval drugs through partnership with drug manufacturers. This innovative program helps ensure there is value aligned with drugs approved through the FDA’s Accelerated Approval process.
• Smart RxAssist**: Starting 7/1/2024, Excellus BCBS has partnered with HealthSmart to offer a medical specialty copay assistance program known as Smart RxAssist (SRxA). SRxA offers members and groups the opportunity to reduce the financial burdens associated with specialty medications that are infused and injected by a physician, home infusion provider or infusion center and billed under the medical benefit. Similarly, as a pharmacy benefit, we have SaveOnSP**, a program providing financial relief for certain specialty prescription drugs. We have already seen positive results from this program with net savings of $14.8 million for our commercial book of business in 2023.

Wishing you all a great rest of the year, Mona Chitre, CPO & President of Pharmacy Solutions

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^{1 Center for Drug Evaluation and Research. “Biosimilar Drug Information.” U.S. Food and Drug Administration, 2019, www.fda.gov/drugs/biosimilars/biosimilar-product-information.}

^{A ltd, R. and M. (n.d.). US Cell & Gene Therapy Market - Focused Insights 2023-2028. www.researchandmarkets.com. Retrieved July 2, 2024, from www.researchandmarkets.com/reports/5806791/us-cell-and-gene-therapy-market-focused-insights}

^{3 Blue Health Intelligence. “Real-World Trends in GLP-1 Treatment Persistence and Prescribing for Weight Management”, May 2024, Issue Brief May 2024: Real-world trends in GLP-1 treatment persistence and prescribing for weight management (bcbs.com) (PDF)}

^{* Health Plan Commercial Rx Book of Business (BoB) Data, these are averages based on BoB data and are not guarantees.}

^{** Available to our self-funded groups, excluding minimum premium and article 47 groups}

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