Managing pharmacy trend can be a challenging task for a client if you don’t know where to focus. Below, we will look at areas that may impact pharmacy trend in the coming years.
Specialty drugs are high-cost medications typically used to treat complex conditions. These products require special handling, in-depth patient education, and proactive clinical management. Specialty drugs have continued to impact trend over the past number of years and will continue to grow market share in the years ahead. These medications make up about 38% of the total pharmacy revenue and are projected to be about 48% by the year 2026.1 Additionally, from a client perspective several commercial groups have already reached a 50% level of spend on their prescription benefit. We anticipate specialty growth will remain steady in the coming years primarily due to research and the number of FDA approvals each year for specialty drugs. Even though growth is expected to remain steady, there are some headwinds for this space coming from increased biosimilars (discussed below) and the approval of generic specialty drugs.
Biosimilars are biological products that are therapeutically similar to reference products which are the current products on the market already FDA approved. These drugs have certain properties that make them different from traditional generic medications. One difference is that although they are similar to the FDA reference, biosimilars are not always interchangeable with the reference products (unless they meet additional requirements showing interchangeability). As of January 2022, the FDA has approved 33 biosimilars, 11 of which are patient-administered products.1 The approval of biosimilars is expected to increase in the coming years, as there are nearly 90 products in the pipeline. One of the top-selling biological drugs will soon be facing biosimilar competition that is likely to have a big market impact. In 2023, Humira biosimilars are going to launch at various points throughout the year, which is expected to help lower trend. Although the exact impact on trend is currently unknown, it is likely to produce some benefit as biosimilars tend to be priced lower compared to the brand-name reference product.
Cell and Gene Therapy
Cell and gene therapy are products and techniques that try to alter a human’s genes or cells to treat or cure rare diseases. Currently, there are 14 FDA-approved gene therapies,1 but this is expected to increase significantly over the coming years. By 2025, 37 more cell and gene therapies are projected to be approved and this will likely lead to an increase in trend.1 There are currently 14 FDA-approved gene therapies, but by 2025, an additional 37 therapies are projected. These therapies are different than specialty drugs, tend to be significantly more expensive, and will likely lead to an increase in trend. Certain products within this space can cost over $1 million dollars for treatment. Although these diseases or conditions are extremely rare, treatment can have a significant impact on trend. With more of these new treatments coming to the market, the probability of utilization will increase and in turn likely increase trend for clients.
Traditional generic and brand name medications can be found at most retail pharmacies. Starting with generics, the prices of these drugs are expected to remain stable in the coming years and are not expected to impact trend in any major way. Generics have typically faced stiff competition and have decreased prices overall from 5-10% annually, which is expected to continue in the coming years. However, there is some uncertainty if price increases in other consumer goods and services will also be seen within the health care sector. A recent analysis by the Kaiser Family Foundation showed that medical care costs in April 2022 only increased by 3.2% compared to April of 2021 vs all other goods and services increasing over 8%.2
Similar to generics, brand name drug prices have typically increased between 4-6% in the past few years and this trend is also expected to remain consistent in the coming years.1 However, the problem with brand-name drugs is that the list prices don’t always equal the net price. Over the past few years, net prices of brand drugs have been in a negative trend! The gross price and the net price difference are expected to remain similar, limiting the impact on the overall trend for brand-name drugs.
In summary, we anticipate trend in the pharmacy benefits space will likely stay consistent with previous years. There should be factors that help drive down trend from new biosimilars and generics. However, opposing factors may drive up trend from new gene and cell therapeutics. As clients look to manage their trends, the factors we’ve discussed in this blog post will require attention. Assistance from pharmacy benefit consultants like PillarRx can help!
- Fein, A. 2022. The 2022 Economic Report on U.S. Pharmacies and Pharmacy Benefit Managers. Drug Channels Institute.
- Wager, E., Ortaliza, J., Hughes-Cromwick, P., (2022, June 3). Overall inflation has not yet flowed through to the health sector. https://www.healthsystemtracker.org/brief/overall-inflation-has-not-yet-flowed-through-to-the-health-sector/#Annual%20percent%20change%20in%20consumer%20price%20index%20for%20urban%20consumers%20(CPI-U),%20April%202021%20-%20April%202022