By Angela Maas

Medical benefit per-member per-month (PMPM) trend continued to increase last year in commercial, Medicare and Medicaid lines of business. That’s one of the findings from Prime Therapeutics LLC’s 14th annual Medical Pharmacy Trend Report, which also unsurprisingly revealed that oncology is the top category of PMPM spend in all three lines of business. And while biosimilars continue to pull share from their oncolytic reference drugs, next year may be the first year to see nononcology medical benefit biosimilars pick up share, pointed out an industry expert at a recent webinar.

Previously known as the Magellan Rx Management Medical Pharmacy Trend Report, the recently released report includes information on 2023 health plan paid claims data on provider-administered medical benefit drugs, which make up more than half of total drug spending in the U.S.

Researchers found that PMPM trend increased for all lines of business. Medicare was up 12.2% for a $78.35 PMPM trend in 2023, commercial rose 11.2% for a $49.08 PMPM, and Medicaid increased 3.9% to a $20.24 PMPM. The report, however, estimates that PMPM trend, while still expected to continue to rise, will drop down to single-digit increases over the next few years.

Annual claims per 1,000 members rose across all three lines from 2022 to 2023, led by commercial, up 13.1% and followed by Medicare, 5.3%, and Medicaid, 0.6%.

Increased use of lower cost agents such as vaccines, corticosteroids and infectious disease drugs actually caused the allowed cost per claim to decline 1.7% from 2022 to 2023 within the commercial line, while Medicare rose 6.6%, and Medicaid also increased 3.3%. At the same time, the use of high-cost drugs — those costing more than $50,000 — increased across all three lines, up 26.8% in commercial, 16.4% in Medicare and 7.1% in Medicaid.

Among the 39 novel medical benefit drug approvals last year were five gene therapies, and expanded labels for oncolytic agents boosted trend, as the oncology class remained the No. 1 category by PMPM spend within all three lines. During an Oct. 24 webinar to discuss the report, Kristen Reimers, R.Ph., clinical pharmacist and senior vice president of specialty clinical solutions for Prime, noted that oncology has been the top spending category for all 14 years of the report, “and in the last five years alone, we’ve seen a 58% trend.”

Oncology support agents’ PMPM spend, however, declined from 2022 to 2023 in all lines of business, with the highest drop in trend — -27.5% — occurring in Medicare, mainly due to colony-stimulating factors. “The annual PMPM for Neulasta and Ziextenzo dropped in 2023 (-48.3% and -82.5%, respectively), due in part to a utilization decrease for both drugs,” noted the report. “The utilization decrease coincides with an increase in oncology immunotherapies, which offer less risk of myelosuppression.”

Within the commercial line of business, biologics for Crohn’s disease and ulcerative colitis made up the No. 2 category in PMPM spend, followed by drugs for multiple sclerosis. In Medicare, ophthalmic injections and immune globulins were the second and third top classes, and in Medicaid, drugs for rare diseases and biologics for Crohn’s/ulcerative colitis were No. 2 and No. 3, respectively.

Keytruda Was No. 1 Trend Driver in All Lines

Merck & Co., Inc.’s cancer blockbuster Keytruda (pembrolizumab) was the No. 1 drug driving trend across all three lines, posting double-digit gains. The immunotherapy has more than 40 indications, with six of those gained in 2023.

Ocrevus (ocrelizumab) from Genentech USA, Inc., a member of the Roche Group, and Takeda Pharmaceuticals U.S.A., Inc.’s Entyvio (vedolizumab) took the second and third spots, respectively, in commercial and Medicaid spend. In Medicare, Regeneron Pharmaceuticals, Inc.’s Eylea (aflibercept) ranked No. 2, but its spend actually declined by 0.9% due to increased use of Genentech’s Vabysmo (faricimab-svoa). That latter agent launched in January 2022 but already ranks in the top 10 in Medicare spend. Bristol Myers Squibb’s Opdivo (nivolumab) rounded out the top three drugs.

Researchers found that within the top 10 drugs based on spend within the commercial line, Remicade (infliximab) from Johnson & Johnson Innovative Medicine and Amgen Inc.’s Neulasta (pegfilgrastim) were the only agents whose spend dropped from 2022 to 2023, “a trend driven by increased utilization of the biosimilars for each drug.” That trend was seen across all the oncology biosimilars: pegfilgrastim, filgrastim, rituximab, trastuzumab and bevacizumab.

Lisa Polakowski, Pharm. D, director of the report, pointed out during the webinar that 2023 was the first time in the 14 years of the report that Neulasta had dropped out of the top 10 Medicare drugs by spend. “The spend continues to decrease year over year,” she noted. “And with it being the No. 10 drug overall for Medicaid, it's actually conceivable that it drops out of the top 10 in Medicaid in 2024 as well.”

“Over the next five to 10 years, we expect to see a wave of new biosimilars entering the market in various therapeutic categories,” said another webinar speaker, Laura Walters, R.Ph., director of specialty clinical solutions. “So we're thinking next year, in ’24, for the first time, there should be impact on the medical benefit outside of oncology” from biosimilars of Eylea and Johnson & Johnson’s Stelara (ustekinumab).

The top 10 highest cost medical benefit drugs by allowed amount per utilizer unsurprisingly included many rare disease agents, with Takeda’s hereditary angioedema therapy Kalbitor (ecallantide) the top agent in commercial at $2.07 million, hemophilia A treatment Obizur (antihemophilic factor [recombinant], porcine sequence), also from Takeda, in Medicare at $1.67 million and Sobi AG’s Gamifant (emapalumab-lzsg), which treats primary hemophagocytic lymphohistiocytosis, in Medicaid at $1.82 million.

“There’s such a low prevalence of rare diseases [that] it can lead to fluctuation and PMPM spend year over year, and the future impact is really difficult to pinpoint,” said another webinar speaker, Laura Walters, R.Ph., director of specialty clinical solutions.

“A big change from 2022 is that Zolgensma [onasemnogene abeparvovec-xioi] is not seen on our Medicaid top spend list,” pointed out Polakowski. The Novartis gene therapy is a one-time treatment for spinal muscular atrophy (SMA). “So utilization numbers are not expected to be consistent year over year, as patient populations change within the line of business, and the members with the condition complete their single-dose treatment.”

Use of another SMA medical benefit agent, Biogen’s Spinraza (nusinersen), also dropped. Polakowski pointed out that in 2022, an SMA pharmacy benefit drug, Genentech’s Evrysdi (risdiplam), received an expanded indication to treat infants younger than 2 months old. “As an oral treatment, we wouldn’t see that in our data because it would be covered under the pharmacy benefit,” she explained. But it’s important to understand “that Evrysdi may be an attractive alternative to the injectable Zolgensma and Spinraza just because of the ease of oral use.”

Results from a survey of 30 medical pharmacy managers covering more than 76 million lives that was conducted in the spring were also included in the report. When asked about how they manage high-cost gene therapies, more than three-quarters — 79% — said they are managing/covering all available gene therapies. Meanwhile, 14% responded that they are managing or covering some, and only 7% said they do not manage or cover these agents. One-quarter of respondents said their plan tracks outcomes for all FDA-approved cell and gene therapies, and 46% said they track them for only some FDA-approved CGTs, but 29% said they do not track them at all.

“Payers reported that they are predominantly using multiple approaches to track the outcomes of therapy,” said Walters. “Their largest challenge to monitoring was patient portability, or, in other words, tracking patients’ outcomes across different plans.”