More treatments, costs for patients with inflammatory bowel disease

Autoimmune diseases, including inflammatory bowel disease (IBD), are one of the main therapeutic categories driving drug trend. IBD can be diagnosed as one of two different diseases: Crohn’s disease (CD) or ulcerative colitis (UC). There is no cure for IBD. Once diagnosed, patients with IBD may require treatment for the rest of their lives. Health care costs for patients with IBD are much higher ($22,987) than health care costs for those without IBD ($6,956).*¹

Generally, IBD drug therapy is tailored to the disease — CD or UC — and its progression. In some cases, treatment may include surgery to remove part of the GI tract.² Many targeted treatments for IBD have come to market in recent years. Existing biologics originally approved to treat other conditions have obtained supplemental indications. And new biosimilars continue to launch. All increase options for patients and providers, but many have the potential to increase costs for payors.³

What is the prevalence of IBD?

One estimate suggests that one in 209 adults are affected by IBD.⁴ Forty-five percent of those diagnosed with IBD who have a prescription are likely to become non-adherent to medications once they start to feel better. Such non-adherence can cause long-term difficulties requiring additional medical interventions and costs.⁵

With the increase of available medications to treat IBD and the rise in the number of patients being diagnosed, utilization is also increasing. Carefully monitoring utilization to ensure appropriate use is key to managing costs in this treatment area.

What are the upcoming notable drugs for IBD in the pipeline?

In 2021, the U.S. Food and Drug Administration (FDA) approved interchangeable biosimilar status for Boehringer Ingelheim’s Cyltezo (adalimumab-adbm), a subcutaneous (SC) tumor necrosis factor (TNF) blocker for treatment of moderate to severe CD or UC. Cyltezo, which is not expected to launch until 2023, is a biosimilar to Humira.⁶ Additional biosimilars to Humira are also expected to launch in 2023.

What cost management strategies are available for IBD therapies?

As more therapies targeting inflammation come to market, patients whose disease doesn’t respond to non-specialty medications often are moved to specialty medications.²⁰ Our utilization management (UM) strategies are designed to help clients manage costs by encouraging use of clinically appropriate, lowest net cost therapeutic categories by leveraging our size and scale. Payors can take actions that will help manage utilization.

Specialty Guideline Management

Robust UM criteria and high-touch clinical review helps ensure safe, clinically appropriate and cost-effective coverage of specialty medications. The Specialty Guideline Management (SGM) program employs comprehensive prospective and concurrent clinical assessments, step therapy, generics first, day-one UM control and medical director review for added clinical oversight. Retrospective clinician review of members’ clinical profiles and claims history helps to ensure clinically appropriate coverage of complex cases.

Advanced Control Specialty Formulary (ACSF) integrates multiple trend management approaches, including hyperinflation management, formulary exclusions, new-to-market drug management, tiering strategy and SGM to help ensure clinically appropriate and cost-effective coverage. Formulary preferencing rules apply before prior authorization (PA) review to help ensure members start on preferred products.

Cross-Benefit Management

Several IBD treatments are also covered under the medical benefit, which should be managed with the same tools as the pharmacy benefit for these drugs. Our proprietary technology platform, Novologix, provides visibility across pharmacy and medical benefits and enables payors to efficiently manage spend in either one. The platform offers real-time, online access to an automated PA process across both benefits with a single front-end system. This enables precision across both benefits for maximum savings.

Intelligent Medication Monitoring

To help control costs, Intelligent Medication Monitoring (IMM), an innovative solution that leverages patients’ increasing digital adoption, engages patients and their providers to facilitate utilization management throughout the duration of drug therapy.

IMM uses advanced analytics, digital outreach and live clinical support to help identify when patients may no longer be benefitting from their medication and intervene appropriately. For IBD, a validated tool (IBD-Control-8) monitors disease activity and condition severity so that providers can optimize drug treatment and identify gaps in care.