Better Managing Psoriasis Across the Duration of Therapy

Innovative strategies to best manage pharmacy costs and care

BRIEFING
June 1, 2021
Vice President, Product Development, CVS Health

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

Rethinking cost management

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 include topicals, systemics (including biologics and oral treatments), phototherapy, and complementary and integrative medicine.

Current biologic treatments for psoriasis 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.https://www.fiercepharma.com/special-report/bimekizumab-10-most-anticipated-drug-launches-2021 A July 2021 decision is expected.

Average monthly treatment cost for psoriasis:
$600 for topicals and $5,000 for biologics2https://www.pharmacytimes.com/view/psoriasis-treatment-cost-comparison-biologics-versus-home-phototherapy

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.

1.7% increase in denial rate for autoimmune enabled by Specialty Guideline Management (SGM) from Q3 2019 to Q4 2020CVS Health Enterprise Analytics, PA Performance Dashboard Q3 2019-Q4 2020, accessed February 16, 2020. Reflects performance of UM programs based on episode outcomes which captures rejects (70 &75) followed by PA (if any) and the fill outcomes. Based on historical behaviors, this may be ~10% of episode. Excludes New to Market Block and claims data for Discount Card, Restricted Data, and certain other clients excluded. Actual results may vary depending on benefit plan design, member demographics, programs implemented by the plan and other factors. P1008210221

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 to address utilization for certain complex therapeutic categories:

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

For all AI biologics, we're bringing more precision to cost management with techniques like specialty quantity 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
 
Insight
 
Criteria & Process Updates
 

39%
of Stelara utilizers may exceed condition-specific FDA recommended dose

Extra level of control recommended

Checkmark FDA recommended dose for Stelara varies by indication and weight

Member-specific dosing limits

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

Monitoring Analysis

39%
of Stelara utilizers may exceed condition-specific FDA recommended dose

Insight

Extra level of control recommended

Checkmark FDA recommended dose for Stelara varies by indication and weight

Criteria & Process Updates

Member-specific dosing limits

Checkmark Applied during PA
Checkmark 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 approx. $21M by updating our process to apply member-specific indication and weight-based dosing limits during PA.4CVS Health Enterprise Analytics, BOB Commercial Clients 1/1/2020 - 1/31/2021, March 2021. Savings projections are based on CVS Caremark data. Actual results may vary depending on benefit plan design, member demographics, programs implemented by the plan and other factors. P1008560321

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.CVS Specialty pharmacy patients only. We use automated monitoring that 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 $1,100 per targeted psoriasis specialty utilizerDuring the initial 10 weeks of SMO program, clients saved ~$1,100 per targeted* specialty utilizer in Psoriasis therapy class: CVS Health Analytics, 2020. Top nine specialty therapies: Rheumatoid Arthritis, Psoriasis, Inflammatory Bowel Disease, Hepatitis C, Multiple Sclerosis, Growth Hormone, Oncology, Hereditary Angioedema and Osteoporosis. Actual results may vary depending on benefit plan design, member demographics, programs implemented by the plan and other factors. *A specialty pharmacy service performed by CVS Specialty for contracted payors. P1007561220

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 is present in natural sunlight. It penetrates the skin and slows the growth of affected skin cells. UVB phototherapy treatment is an effective treatment for psoriasis and can be an economical and convenient choice.https://www.psoriasis.org/phototherapy/

Average annual treatment cost of home phototherapy: $5,000https://www.pharmacytimes.com/view/psoriasis-treatment-cost-comparison-biologics-versus-home-phototherapy

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.

In a new pilot launching this year, we will offer UVB phototherapy treatment via an app-controlled, connected UVB device that members can use at home. High-touch services will support adherence and the member experience. Pilot results will be evaluated for impact on pharmacy costs based on the benefit for patients throughout therapy.

Want to learn how proactive psoriasis management can lower your plan's specialty costs? Ask Us
BRIEFING
June 1, 2021
Vice President, Product Development, CVS Health

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.