Better managing psoriasis across the duration of therapy

Psoriasis: an immune system disease that causes a rapid increase in skin cell production, resulting in raised, scaly patches that can itch, crack and bleed.

• Affects 2.4% of Americans — about 8 million people
• Approximately 20% of patients have moderate to severe disease

Rethinking cost management for psoriasis

To stay ahead of the market and maximize savings for our clients and their plan members, we employ our clinical expertise, industry surveillance and reporting tools.

Our process starts with proactively monitoring the drug pipeline, inclusive of expanding indications and new clinical care guidelines. Available treatments for psoriasis include topicals, systemics (including biologics and oral treatments), phototherapy and complementary and integrative medicine.

Current biologics include: Cimzia (certolizumab pegol), Enbrel (etanercept), Humira (adalimumab), Remicade (infliximab), Simponi (golimumab) and Simponi Aria (golimumab), Stelara (ustekinumab), Cosentyx (secukinumab), Siliq (brodalumab), Taltz (ixekizumab), Orencia (abatacept), Ilumya (tildrakizumab-asmn), Skyrizi (risankizumab-rzaa), and Tremfya (guselkumab)

UCB’s bimekizumab would provide another subcutaneously administered option for treatment of plaque psoriasis. UCB is seeking U.S. Food and Drug Administration (FDA) approval for bimekizumab for adults with moderate to severe plaque psoriasis.¹ The FDA deferred action due to the COVID-19 pandemic.

We aggressively prevent unnecessary utilization through our enhanced utilization management (UM) controls. To do this, we balance clinical appropriateness and unit cost at the therapeutic category and ensure coverage for appropriate utilization with robust criteria and high-touch medical director review.

3.7% increase in denial rate for autoimmune enabled by enhanced Specialty Guideline Management (SGM) from 2019 to Q2 2021²

Precision and continuous refinement

Continuous evaluation of solutions ensures that we can help our clients manage costs while ensuring clinically appropriate coverage of specialty medications. Our Enhanced SGM solution provides clients with greater choice and flexibility to have more stringent prior authorization (PA) criteria including additional documentation requirements to address utilization for certain complex therapeutic categories:

• Requires prior use of non-specialty drugs
• Limits coverage to select diagnoses and reduces approval duration
• Promotes less costly, therapeutically equivalent therapies

These strategies result in increased appropriate and durable denials. For all AI biologics, we're bringing more precision to cost management with techniques like efficacy assessment for renewal and indication- and weight-based dosing limits.

Case Study

Stelara is indicated for multiple conditions—plaque psoriasis, psoriatic arthritis, Crohn's disease and ulcerative colitis. Stelara dose should be determined using indication and weight.

Monitoring Analysis:

30% of Stelara utilizers may exceed condition-specific FDA recommended dose³

Insight:    

Extra level of control recommended

• FDA recommended dose for Stelara varies by indication and weight

Criteria & Process Updates:

Member-specific dosing limits

• Applied during PA
• Prospectively prevents inappropriate dose escalation and avoids wasteful spend

Delivering up to 8.4 percentage point reduction of high-dose Stelara use for a gross cost savings of approximately $21M by updating our process to apply member-specific indication and weight-based dosing limits during PA.⁴

We also monitor supply on hand. While standard quantity limits manage quantity for a single fill, CVS Health is able to help manage the patient’s supply on hand throughout the year to reduce waste.⁵ Supply Management Optimization triggers personalized interventions during the refill process to help encourage patient behavior without requiring a benefit change. Artificial intelligence helps more efficiently manage drug therapy using a one-year lookback of dispensing data versus the month-to-month industry standard. The patient is contacted in their preferred channel, digitally or telephonically, and provided a preferred refill date to help avoid excess supply on hand.

Clients saved about $1,000 per targeted psoriasis specialty utilizer⁶

Changing the treatment landscape with innovation

There are many novel approaches to help members manage pre-biologic therapies and remain on effective, lower-cost therapies. Forty million people in the U.S. suffer from psoriasis, vitiligo or eczema and have insufficient treatment options for phototherapy. UVB rays are present in natural sunlight. They penetrate the skin and slow the growth of affected skin cells. UVB phototherapy is an effective treatment for psoriasis and can be an economical and convenient choice.⁷

Average three-year treatment cost of home phototherapy: $5,000⁸

Given the clinical and cost benefit of UVB treatment, we have included it as one of the necessary prerequisite therapies in our psoriasis clinical policies and criteria. We are working on expanded approaches for using UVB phototherapy for better care and cost management.

A new pilot launched in October 2021 offers UVB phototherapy treatment via an app-controlled, connected UVB device that members can use at home. High-touch services support adherence and the member experience. Currently we have five clients participating in the pilot; we will continue to assess and consider options for the best next steps based on our learnings.

At CVS Health, we continue to invest, test, learn and identify new ways to create and exceed the results our clients expect – aggressively managing specialty costs while driving better health outcomes and experience.

Originally published on June 1, 2021 and updated with new statistics on October 28, 2021.

The source for data in this document is CVS Health Enterprise Analytics, unless otherwise noted. Actual results may vary. This document contains references to brand-name prescription drugs that are trademarks or registered trademarks of pharmaceutical manufacturers not affiliated with CVS Health.