Medical Pharmacy Trend Report™
Contributors
Lisa Polakowski, PharmD, MBA Director, Medical Pharmacy Trend Report
Laura Walters, RPh Director, Specialty Clinical Solutions
Ben Messerli, ASA, MAAA Manager, Actuarial Services
Mel Moktan Associate Actuarial Analyst
Kristen Reimers, RPh Senior Vice President, Specialty Clinical Solutions
Shelae Cheng Marketing Principal, Brand Marketing Strategy
Katie Lockhart, MS Director, Forecasting and Pharmacoeconomics
Angela Harris Senior Analyst, Forecasting and Pharmacoeconomics
Michael Keiser, PharmD, MBA Director, Specialty Clinical Solutions
Victoria Facchini, PharmD Director, Specialty Clinical Solutions
Payer advisory board
Martin Burruano, RPh Pharmacy Advisor Independent Health
Connie Estep, PharmD Director, Specialty Clinical Solutions
Natalee Felten, PharmD, BCPS Clinical Pharmacist, Specialty Clinical Solutions
Rachael Prusi, PharmD, MSGH Director, Specialty Clinical Solutions
Samantha Decker, PharmD Clinical Pharmacist, Specialty Clinical Solutions
Devon Trumbower, PharmD, BCPS Clinical Pharmacist, Specialty Clinical Solutions
Simone Ndujiuba, PharmD, BCOP Director, Clinical Strategy and Innovation, Oncology
Sneha Sharma, PharmD Director, Specialty Clinical Solutions
Sean Shirk, PharmD, BCGP Director, Specialty Clinical Solutions
Prerak Parikh, PharmD Director, Specialty Clinical Solutions
Mike Ochowski, RPh Pharmacy Informatics & EMR Support GHC-SCW
Andy Killpack, PharmD Director, Specialty Clinical Solutions
Amy Ware, PharmD Director, Specialty Clinical Solutions
Michael Szatkowski, PharmD, MBA, BCPS Director, Specialty Clinical Solutions
Michelle Booth, PharmD Senior Director, Specialty Clinical Solutions
YuQian Liu, PharmD Senior Director, Specialty Clinical Solutions
Alina Liang, PharmD Senior Clinical Project Manager, Clinical Strategy and Innovation
Jordan Almazan, PharmD, AAHIVE, BCGP Director, Clinical Strategy and Innovation
David Eckwright, PharmD, MHI, CSP Senior Director, Specialty Analytics and Informatics
Alexandra Wilson, PharmD Clinical Program Pharmacist, Specialty Analytics and Informatics
Patrick Gill, RPh Director of Pharmacy, Commercial Horizon BlueCross BlueShield of New Jersey
Scott McClelland, PharmD Vice President, Pharmacy Florida Blue
Methodology
The 2024 edition of the Prime Therapeutics Medical Pharmacy Trend Report (formerly known as the Magellan Rx Medical Pharmacy Trend Report) was developed using medical pharmacy industry standard methodologies, calculations, guidance from medical drug management experts and feedback from previous trend reports. Results were based on a non-continuous population over the five years analyzed. The trend forecast utilized various modeling techniques, including time series modeling, product mapping, custom component modeling, assumption-based modeling and forecasting by analogy, to generate trend forecasts at a line-of-business level.
This report includes research data obtained through a survey of payers conducted in spring 2024 to deliver a comprehensive view of payer perceptions and health plan actions related to provideradministered infused or injected drugs paid under the medical benefit, also referred to as medical benefit drugs. These medical benefit drugs are commonly used to treat chronic, progressive, incurable medical disorders.
Health plan claims data
Medical benefit drug utilization and trend data were collected through secondary analyses of commercial, Medicaid and Medicare Advantage health plan medical paid claims data for the most recent calendar years. Claims data was analyzed for medical pharmacy utilization across 1,106 health care common procedure coding systems (HCPCS) and several outpatient sites of service.*
Analyses compared medical claims data from 2023 to data from 2022. In some cases, the past five years were analyzed to show a longer period of year-over-year spend and trend. All data includes allowed amount costs directly from health plans for medical drugs only. Administration codes were analyzed separately and discussed on Page 14 and in the appendix, Pages 59 and 60.
Biologic drugs for autoimmune disorders (BDAIDs) Cimzia, Entyvio, Orencia, Remicade
Enzyme replacement therapy Cerezyme, Fabrazyme, Lumizyme, Nexviazyme
Immune globulin Gammagard Liquid, Gamunex, Hizentra, Privigen
Multiple sclerosis Ocrevus, Tysabri
Oncology Darzalex, Imfinzi, Keytruda, Opdivo
Oncology support Antiemetics, CSFs, ESAs
Ophthalmic injections Avastin (compounded/repackaged), Eylea, Lucentis, Vabysmo
Rare disease
Amvuttra, Spinraza, Tepezza, Zolgensma
39 novel medical pharmacy drug approvals in 20231, 2, 3
2023 top spend drugs' impact on trend Figure 2
Utilization by cost
• Utilization increased for each cost category for commercial and Medicare in 2023.
• Medicaid saw decreased utilization for lower-cost therapies (less than $100 annual cost/utilizer and $1,000–$10,000 annual cost/ utilizer).
• There were double-digit increases in utilizers with an annual cost of more than $50,000 in both commercial (26.8%) and Medicare (16.4%).
Top drug spends
• Keytruda continued to be a double-digit trend driver for commercial (21.2%), Medicare (18.3%) and Medicaid (16.7%).
• Ocrevus and Entyvio continued to drive trend in commercial and Medicaid due to an increase in both claims and utilizers.
• Eylea held the second spot by PMPM spend in Medicare, although spend decreased by 0.9% due to increased Vabysmo uptake.
• Opdivo spend in Medicare rose due to increased utilization in urinary system and respiratory cancers.
*Reflects change in utilization of drug and therapy combinations for the various annual cost/utilizer categories shown.
2023 utilization trend by annual cost* Figure 3
Allowed cost per claim Figure 4
Annual claims per 1k members utilization Figure 5
Allowed cost per claim
• Cost per claim decreased by 1.7% in commercial, driven by higher utilization of lower cost drug classes such as vaccines (+169.6% claims volume), corticosteroids (+12%) and infectious disease (+14.2%). Within the top 20 drugs by spend, Remicade (-17.8%) and Mvasi (-12.4%) had the greatest decreases in cost per claim.
• Cost per claim increased for the government businesses, with a 6.6% trend in Medicare and 3.3% trend in Medicaid.
• In the top 20 Medicare drugs, Imfinzi (+31.1%) and Tepezza (+25.3%) had the greatest increases in cost per claim. For Medicaid, the greatest increase in cost per claim was in the unclassified code (J3590). Total spend for drugs over all unclassified codes was $0.27 PMPM.
Annual claims per 1k members
• Commercial posted a double-digit increase in claims volume (13.1%) in 2023. The top three drugs that contributed to this trend were dexamethasone, Rocephin and Prevnar 20.
• Medicare claims volume increased by 5.3% in 2023. Prevnar 20, DepoMedrol, COVID-19 vaccines and Vabysmo were the top contributors to this trend.
• Medicaid claims volume remained flat at 0.6%. Claims volume increases for pneumococcal and COVID-19 vaccines were offset by decreases in Makena and injectable corticosteroids. The FDA withdrew Makena's approval in April 2023 as confirmatory trials did not verify clinical benefit.
Forecast
• Expect further biosimilar movement — Eylea, Stelara and Soliris all have approved biosimilars that are expected to launch in the next few years.
• Monoclonal antibodies for Alzheimer's: Kisunla was approved in July 2024, joining Leqembi as a potential trend contributor in the Medicare space.
• CAR T-cell therapies Abecma, Carvykti and Breyanzi received approvals as earlier-line therapies in 2024, which may increase utilization of these agents.
• Gene therapies Casgevy, Lyfgenia and Kresladi (pending FDA approval) have the potential to impact the rare disease therapy category in future years.
*Forecasted trends are shown for 2024.
Medical pharmacy trend drivers
Overall landscape
The medical pharmacy landscape continued to evolve, with 39 novel drug approvals for medical benefit drugs in 2023.1, 2, 3 These approvals accounted for 55% of all novel approvals in 2023. Five gene therapies were approved: Casgevy and Lyfgenia for sickle cell disease, Elevidys for Duchenne muscular dystrophy (DMD), Roctavian for hemophilia A and Vyjuvek, a topical gene therapy for dystrophic epidermolysis bullosa (DEB). Expanded indications for oncology medications continued to drive overall trend across the medical benefit.
Utilization versus cost contributors
For commercial plans, claims volume had the highest influence on overall trend for 2023. The largest increase in utilization was in low-cost drug categories such as vaccines (+169.6% claims volume), corticosteroids (+12%) and infectious disease (+14.2%). In the government businesses, allowed cost per claim was the main trend driver as utilization shifted from lower-cost drugs to higher-cost therapies. Utilization of high-cost drugs (drug spend greater than $50,000 per claim) increased by 26.8% in commercial, 16.4% in Medicare and 7.1% in Medicaid. The increase in utilization was two-fold, driven by more high-cost therapies entering the market coupled with the return of health care utilization to pre-pandemic levels.
Vaccines
Vaccines are included in the 2023 report, as there have been several notable events in this class. The COVID-19 public health emergency ended in May 2023, and COVID vaccines have received full FDA approval for yearly doses. Three new vaccines for respiratory syncytial virus were approved: Abrysvo, Arexvy and Beyfortus. Prevnar 20 (pneumococcal vaccination) was a top contributor to utilization trend in commercial and Medicare. Two key developments that led to increased utilization occurred in 2023: Prevnar 20 received approval for pediatric patients and the CDC guidelines were updated to recommend Prevnar 20 for adults 65 years and older, even if they have already received pneumococcal vaccination with PCV13 or PPSV23.4
2023 trend for top 20 drug therapy categories* Figure 8
*Rank based on PMPM spend includes positive or negative changes 2022–23. See Pages 39–44 for drug and category-level breakdowns.
2023 trend for top 20 drugs* Figure 9
Medical pharmacy trends
Commercial
Commercial experienced an overall trend of 11.2% PMPM with a $4.92 PMPM increase from 2022 to 2023. Oncology remained the highest spend class in 2023 at $19.91 PMPM, up from $17.61 in 2022 (+13%), and accounted for 40.6% of the overall PMPM.
The top 10 drug therapy categories composed 77% of the 2023 PMPM. BDAID: Crohn’s/ulcerative colitis had the second-highest percentage of overall spend (9.1%) with a 6.2% increase in PMPM from $4.22 in 2022 to $4.48 in 2023 (Pg. 16). All the top 10 drug categories had positive PMPM trends in 2023, except for colony-stimulating factors (-5.3%) and antihemophilics (-5.4%).
Ophthalmic injections had a 17.2% increase in spend, which was the largest increase of all the top ten categories. Continued increases in Eylea utilization and uptake of higher-cost Vabysmo contributed to increased spend in this category.
Keytruda was the top drug by spend at $4.48 PMPM, a 21.2% increase in 2023 (Pg. 9, Fig. 12). Keytruda trend was largely driven by a nearly 18% increase in utilizers, although claims per utilizer remained flat (+0.8%). Remicade (-26%) and Neulasta (-6.7%) were the only drugs in the top 10 with decreased spend in 2023, a trend driven by increased utilization of the biosimilars for each drug.
Utilization (+13.1%) (Pg. 6, Fig. 7) was also a trend driver due to increased utilization of low-cost corticosteroids and vaccines. Trend was slightly offset by a 1.7% decrease in cost per claim. Hospital outpatient claims were 43.1% of total claim volume (-1.4% from 2022), likely contributing to a decrease in cost. Commercial was the only line of business (LOB) to see a decrease in hospital outpatient claims percentage.
2022–2023 top drug therapy categories by PMPM spend Figure 10
2023 oncology vs. oncology support vs. non-oncology spend Figure 11
2023 commercial top medical benefit drugs by spend Figure 12
2022–2023 commercial components of change* Figure 13
$0.13
$0.08
*See glossary on Page 61 for definition of terms.
Entyvio (Crohn’s/UC)
Opdivo (oncology)
Neulasta (oncology support: GCSF)
Gammagard Liquid (immune globulin)
Tysabri (MS)
Perjeta (oncology)
Remicade (Crohn’s/UC)
Darzalex Faspro (oncology)
Neulasta (oncology support: GCSF)
Opdivo (oncology)
Entyvio (Crohn’s/UC)
Ocrevus (MS)
Keytruda (oncology)
Gammagard Liquid (immune globulin)
Tysabri (MS)
Perjeta (oncology)
Remicade (Crohn’s/UC)
Darzalex Faspro (oncology)
Ocrevus (MS)
Keytruda (oncology)
2022–2023 top drug therapy categories by PMPM spend Figure 14
Medicare
Medicare’s overall spend PMPM increased 12.2% in 2023. This trend reflects a faster rate of growth than 2022 and is comparable to the pre-pandemic Medicare trend (Pg. 5, Fig. 6). Medicare trend was mainly driven by a 6.6% increase in cost per claim (Pg. 6, Fig. 7). Utilization increased 16.4% for high-cost therapies (drug cost greater than $50,000 per year) (Pg. 3, Fig. 3).
The top 10 spend categories accounted for 84.3% of spend in Medicare. Oncology spend was $42.26 PMPM, a 12.3% increase. Keytruda, Opdivo, Darzalex Faspro, Tecentriq and Imfinzi continued to represent the majority of spend in this class, with all of these drugs having seen spend increases this year (Pg. 11, Fig. 16). Spend for non-oncology drugs increased by 16.2%, led by ophthalmic injections, immune globulins and drugs for osteoporosis and MS.
The oncology support therapy category represented a key decrease in trend, which was seen across all lines of business (LOBs), but most notably in Medicare. This trend decrease was driven primarily by 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. The utilization decrease coincides with an increase in oncology immunotherapies, which offer less risk of myelosuppression.
The novel therapy Vabysmo first entered the market in January 2022 and is now ranked in the top 10 spend due to a substantial uptake in utilization (Pg. 11, Fig. 16). Eylea remained in the top 10 (No. 2 overall), although it showed a decrease in trend (-0.9%) in 2023 due to diminishing claim volume (-1.3%) due to competition in the class.
2023 oncology vs. oncology support vs. non-oncology spend Figure 15
2023 Medicare top medical benefit drugs by spend Figure 16
2022–2023 Medicare components of change* Figure 17
Keytruda (oncology)
$0.23
$0.13
Eylea (ophthalmic injections)
*See glossary on Page 61 for definition of terms.
Opdivo (oncology)
Darzalex Faspro (oncology)
Tecentriq (oncology)
Gammagard Liquid (immune globulin)
Ocrevus (MS)
Vabysmo (ophthalmic injections)
Prolia (osteoporosis)
Imfinzi (oncology)
Tecentriq (oncology)
Darzalex Faspro (oncology)
Opdivo (oncology)
Eylea (ophthalmic injections)
Keytruda (oncology)
Gammagard Liquid (immune globulin)
Ocrevus (MS)
Vabysmo (ophthalmic injections)
Xgeva/Prolia (osteoporosis)
Imfinzi (oncology)
2022–2023 top drug therapy categories by PMPM spend Figure 18
Medicaid
Medicaid trend was 3.9% with a $0.76 PMPM increase from 2022 to 2023. Utilization increased by 0.6% (Pg. 6, Fig. 7) due to an increase in utilizers in the top spend categories: oncology, BDAIDs: Crohn’s disease/ulcerative colitis and multiple sclerosis.
The top 10 drug categories contributed 70.1% of the overall PMPM spend in 2023. Oncology drugs remained the highest spend class, with $6.55 PMPM (+5.3%) in 2023, and accounted for 32.3% of total spend. Only five of the top 10 drug categories experienced positive PMPM trend, which differs from commercial and Medicare.
Keytruda remained the top drug by spend at $1.68 PMPM (+16.7%) (Pg. 13, Fig. 20). Keytruda received approval for additional indications in 2023, leading to a 17.4% increase in utilizers. Ocrevus (+16% PMPM) and Entyvio (+18.8% PMPM) ranked second and third, respectively, driven by increased utilization. Gammagard Liquid had the largest PMPM trend (38.6%) of the top drugs, driven by both increased utilizers and cost per claim.
The rare disease category, despite ranking second in overall spend, had a 5.2% PMPM decrease in 2023. CNS: Rare Disease ranked seventh, although spend decreased by 41.5%. Exondys 51 (-6.3%) and Spinraza (-24.4%) experienced decreased spend due to lower utilization, although they still rank among the top 10 drugs. A single claim for Elevidys for $2.6 million was the main driver of spend in the unclassified code, accounting for $0.20 PMPM spend (Pg. 4 and Pg. 44, Fig. 118). Volatility in annual volume is expected in these classes depending on member mix.
Colony-stimulating factors were a significant driver in offsetting overall trend (-11.2% PMPM trend), with a 12% decrease in claim volume. There was also a shift in utilizers from higher-cost Neulasta (-6.5%) to Udenyca (+38%) and Fulphila (+109.7%).
BDAID: Crohn’s disease/ ulcerative colitis
2023 oncology vs. oncology support vs. non-oncology spend Figure 19
2023 Medicaid top medical benefit drugs by spend Figure 20
Medicaid components of change* Figure 21
*See glossary on Page 61 for definition of terms.
Gammagard Liquid (immune globulin)
Ocrevus (MS)
Hemlibra (antihemophilics)
Opdivo (oncology)
Spinraza (rare disease)
Botox (botulinum toxins)
Exondys (rare disease)
Entyvio (Crohn’s/UC)
Neulasta (oncology support: GCSF)
Keytruda (oncology)
Gammagard Liquid (immune globulin)
Ocrevus (MS)
Hemlibra (antihemophilics)
Opdivo (oncology)
Spinraza (rare disease)
Botox (botulinum toxins)
Exondys (rare disease)
Entyvio (Crohn’s/UC)
Neulasta (oncology support: GCSF)
Keytruda (oncology)
Administrative code reimbursement
Hospital outpatient claims represented 43.1% of commercial, 29.1% of Medicare and 47.7% of Medicaid claims in 2023. The spend impact on the administration of medical benefit drugs was dependent on the site of service (SOS). For commercial and Medicare, the administration of chemotherapy treatment was two to four times more costly in the hospital outpatient setting compared to the physician’s office. Chemotherapy administration was the top spend for these two lines of business (LOBs), with a PMPM increase of 9% in commercial, while Medicare spend remained flat. Differences in cost between SOS in Medicaid was negligible. The top spend for Medicaid was pediatric immunization (up to age 18), almost all of which was administered in physicians’ offices. In Medicare, the administration of intravitreal/ophthalmic agents had the second-highest spend, although overall spend was down 9.3% in 2023, led by decreased administration in physicians’ offices (-13.8%). (See Pgs. 59-60 for more details.)
2023 top administrative codes by PMPM for hospital outpatient and physician office Figure 22
Commercial
CPT code and description
96413 Chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug
96365 Intravenous infusion for therapy, prophylaxis or diagnosis; initial, up to 1 hour
96375 Therapeutic, prophylactic or diagnostic injection; each additional sequential intravenous push of a new substance/ drug
96361 Intravenous infusion, hydration; each additional hour
96372 Therapeutic, prophylactic or diagnostic injection; subcutaneous or intramuscular
Medicare
CPT code and description
96413 Chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug
67028 Intravitreal injection of a pharmacologic agent (separate procedure)
96365 Intravenous infusion for therapy, prophylaxis or diagnosis; initial, up to 1 hour
96374 Therapeutic, prophylactic or diagnostic injection; intravenous push, single or initial substance/ drug
20610 Under general introduction or removal procedures on the musculoskeletal system
code and
90460 Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; first or only component of each vaccine or toxoid administered
96413 Chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug
96372 Therapeutic, prophylactic, or diagnostic injection; subcutaneous or intramuscular
Therapeutic, prophylactic, or diagnostic injection; intravenous push, single or initial substance/drug
96365 Intravenous infusion, for therapy, prophylaxis or diagnosis; initial, up to 1 hour
Medical benefit categories
Rare disease*
Rare disease therapies continued to be an area of growth and innovation, with 11 FDA approvals for medications in this class between 2022 and 2023; however, there remains a significant unmet need for new therapies to address low-prevalence diseases. Forecasts project growth will continue over the next three years at a rate of 47.6% in commercial, 77.7% in Medicare and 32.7% in Medicaid.
Rare disease appeared in the top 10 classes by spend across all across all lines of business (LOBs) (Figs. 10, 14, 18). Rare disease PMPM trend increased for commercial and Medicare but decreased for Medicaid. Major contributors to spend for commercial included Tepezza, Exondys 51, Gamifant and Amondys 45. Medicare had a 48.8% PMPM trend, largely driven by spend increases for Reblozyl and Tepezza (which both gained expanded indications in 2023) as well as Amvuttra and Givlaari. The medications contributing to PMPM trend decrease for Medicaid included Exondys 51, Tepezza and Spinraza.
Overall, drugs for CNS: rare diseases saw drops in utilization across all three LOBs (-72.2% commercial, -100% Medicare, -30.8% Medicaid), notably influenced by changes in Spinraza and Radicava. While spend percentage and PMPM can be low for these medications, their annual allowed amount per utilizer can be significant; as seen on Page 45, some of the 10 highest-cost drugs were more than one million dollars per utilizer annually.
Biologic drugs for autoimmune disorders (BDAIDs)*
Overall, we continued to see increases in BDAID spend for commercial and Medicaid (6.1% and 3.3% respectively), driven mostly by higher Entyvio utilization. Given the approval of Entyvio SQ in September 2023, we anticipate a shift in Entyvio spending to the pharmacy benefit in upcoming years. Remicade is still among the top 10 drugs for the commercial line of business (LOB) (Pg. 9, Fig. 12), although usage and spend have decreased across all LOBs. The decrease in Remicade impact is likely due to a shift to biosimilar products (Avsola, Inflectra and Renflexis; Pg. 57, Fig. 150) as well as drugs such as Skyrizi and Rinvoq receiving FDA approval for additional indications within the autoimmune space.
In Medicare, BDAID spend decreased by 0.2%. Spend in the BDAID: rheumatoid arthritis category was flat (-$0.01 PMPM) while spend in BDAID: Crohn’s/ulcerative colitis decreased by 1.8% (-$0.03 PMPM) in 2023. For BDAID: Crohn’s/ulcerative colitis, Medicare saw an increase in Entyvio utilizers (+7.2%) and cost per claim (+1.7%) however, these increases were largely countered by lower spending on other medicines, such as Stelara SQ (-42.3%), Renflexis (-37.2%), Inflectra (-23.6%) and Remicade (-7.5%).
2023 % of medical drug spend Figure 29
2023 cost per claim Figure 30
BDAIDS — deep dive
Commercial
In Crohn’s and ulcerative colitis, Entyvio PMPM increased from $2.00 to $2.18 in 2023 (+9.2%) (Pg. 18, Fig. 32). Market share for Entyvio decreased from 34.7% in 2022 to 32.9% in 2023 (Pg. 48, Fig. 126); however, this was offset by increased cost per utilizer (+$1,153). Remicade market share fell from 40.2% to 32.9% as utilization shifted to infliximab biosimilars in 2023. Inflectra gained the most market share of the biosimilars. Inflectra had an annual cost per utilizer of $19,440 compared to Remicade’s $23,109, which helped offset spend.
Medicare
Rheumatoid arthritis trend remains relatively stable (a decrease of $0.01 PMPM from 2022) driven by decreases in cost, as utilization increased only modestly. Orencia dampened trend with a decrease of 6.4% PMPM, where cost per claim decreased 7.5%. The claim volume and number of utilizers stayed the same.
Crohn’s and ulcerative colitis saw a small decrease of $1.30 PMPM from $1.33 PMPM in 2022, driven by decreased utilization from a majority of products and balanced by the continued growth of Entyvio utilization. Entyvio utilizers increased 7.2% in 2023. Skyrizi IV entered this space at 2.5% market share with its approval for Crohn’s disease in mid2022 (Pg. 48, Fig. 127). Skyrizi IV/SC received an expanded indication for ulcerative colitis in June 2024, making it a drug to watch in the future.
Commercial Crohn’s/UC — top PMPM spend drugs* Figure 32
BDAIDS — deep dive (cont.)
Medicaid
Crohn’s and ulcerative colitis saw a decrease of $0.02 PMPM from 2022. This was driven largely by lower Remicade spend, which decreased from $0.32 in 2022 to $0.22 in 2023.
Remicade saw a 29.9% decrease in PMPM spend compared to 2022.
Entyvio spend increased 18.8% PMPM from 2022, driven by increased utilization (which grew by 12.1%) and increased costs (+5.9%). Entyvio has an annual cost per utilizer of $43,978 compared to $13,675 for Remicade (Pg. 48, Fig. 128). The market share for these drugs is nearly equal: 29% for Entyvio and 30.6% for Remicade. As Entyvio continues to increase in market share, higher spend in this category due to higher costs should be expected. The impact of Enyvtio SQ’s approval on this category’s market basket dynamics will be worth monitoring in the coming years.
Medicare Crohn’s/UC — top PMPM spend drugs* Figure 33
Entyvio Remicade Stelara SQ Inflectra Stelara IV Renflexis
Medicaid Crohn’s/UC —
top PMPM spend drugs* Figure 34
Remicade Stelara SQ Inflectra Skyrizi Stelara IV
Entyvio Remicade Stelara SQ Inflectra Skyrizi Stelara IV
Entyvio
Oncology*
Commercial
Commercial oncology PMPM rose by 13% in 2023. Top spend drivers included Keytruda, Darzalex Faspro, Enhertu and Opdivo. Expanded indicatons for Keytruda (lymphoma, respiratory, solid tumors, urinary system and GI), Opdivo (melanoma in pediatric and adults) and Enhertu (HER2low breast cancer and HER2+ NSCLC) drove utilization increases. Darzalex Faspro (+23.1% claims) continued to pull market share from Darzalex (-23.2% claims).
Medicare
Oncology utilization in Medicare remained flat (-0.8%) in 2023, although PMPM increased 12.3%. Much like commercial, increases in Keytruda, Darzalex Faspro and Opdivo utilization drove spend. Agents for urinary system cancers, Padcev (+$0.48 PMPM, 188.1% increase) and Pluvicto (+$0.30 PMPM, 243.5% increase), also drove growth in this category. Vidaza, 5-Fluorouracil, Gemzar and Dacogen were the largest contributors to decreased utilization.
Medicaid
Medicaid PMPM spend growth in oncology remained lower (+5.3%) compared to commercial and Medicare. Tecentriq had the largest spend decrease (36.4%), with a 41.5% decrease in claims. Utilization decreases for Tecentriq were most prevalent in respiratory, liver and bladder cancers. In December 2022, the accelerated approval for urothelial carcinoma was removed due to failure to meet overall survival endpoint.
2023 % of medical drug spend Figure 37
Commercial deep dive
Breast cancer
Breast cancer led commercial spend for oncology on a PMPM basis and accounted for 25.3% of oncology spend for this LOB. PMPM spend increased from $4.52 in 2022 to $5.03 PMPM in 2023 (+11.3%), mostly due to increased Keytruda and Enhertu utilization. Keytruda spend increased from $0.97 in 2022 to $1.21 in 2023, a 24.7% increase. In 2023, Keytruda accounted for 24.1% of overall breast cancer spend, followed by Perjeta (17.8%) and Enhertu (9.8%). Of the top six drugs for this condition, only Kanjinti did not see increased cost per claim, remaining essentially flat at -0.8%.
Enhertu received a new indication for use in HER2-low breast cancer in August 2022, which led to a 75% increase in claims in 2023. Enhertu spend also rose to $0.49 PMPM in 2023, up 78.5% from the 2022 PMPM of $0.28. The number of Enhertu utilizers increased 45.3% for breast cancer in 2023. Drug spend for breast cancer may continue to increase as efforts focus on earlier detection and treatment in women as young as age 40.5-8
Phesgo Kanjinti Kadcyla Enhertu Perjeta Keytruda
Commercial deep dive
Gastrointestinal cancer
Gastrointestinal (GI) cancer is the third ranked cancer type by PMPM for commercial in 2023 and had the second highest PMPM increase of cancer types for this line of business. The GI cancer PMPM increased 24% from $1.66 in 2022 to $2.06 PMPM in 2023. The top five drugs contributing to GI cancer spend experienced a significant increase in both claims and utilizers.
Opdivo had both the greatest spend at $0.39 PMPM and contributed 6.5% to trend for GI cancers, which was the highest trend contributor. For Opdivo, the cancer types with significant PMPM increases were colorectal (60%), esophageal (38.8%) and gastric cancers (38.3%).
Keytruda retained the second rank by PMPM spend at $0.29 (+28.5%) for 2023, making this one of the very few categories where Keytruda did not take the top spot.
Two bevacizumab biosimilars, Mvasi and Zirabev, were within the top six drugs for spend for GI cancers in 2023 due to high utilization, particularly for colorectal cancer. Mvasi had a PMPM increase of $0.03 (18.5%) while Zirabev saw a slight decrease of $0.01 PMPM (-7%).
Imfinzi had a significant increase in utilization for GI cancers due to expanded indication for locally advanced or metastatic biliary tract cancer granted in September 2022. Bile duct cancer was responsible for the majority (68.8%) of Imfinzi spend, with a three-fold PMPM increase from $0.06 in 2022 to $0.18 in 2023.
*Due to rounding, totals may not add up accurately. **See glossary on Page 61 for definition of terms. Top oncology spend by cancer type Figure 42
2022–2023 GI cancer commercial components of change** Figure 44
Figure 46
Medicare deep dive
Respiratory cancer
Respiratory cancers remained the top ranked cancer type by total spend for Medicare in 2023, accounting for 22.5% of all oncology spend. Spend increased 5.3% from $9.03 to $9.51 PMPM in 2023. Trend was driven by cost and utilization increases, while the drug mix remained stable.
Keytruda, Tecentriq and Imfinzi made up 79% ($7.46 PMPM) of total oncology spend. Keytruda and Tecentriq saw increases in claims, utilizers and cost per claim. Imfinzi had a 2% decrease in claims, although utilizers increased 4.9% and cost per claim rose 23.2% in 2023.
Keytruda received expanded approvals in 2023 as a single-agent adjuvant treatment in early-stage NSCLC (Stage IB, II, or IIIA); and as a neoadjuvant treatment in combination with platinum-containing chemotherapy in resectable NSCLC, then continuing as adjuvant singleagent treatment after surgery. Competition for market share between Keytruda and Tecentriq in early-stage NSCLC will be an item to watch in future reports.
The main drug mix change was the shift from Alimta to Pemfexy in 2023. Alimta spend decreased from $0.76 to $0.16 PMPM in 2023, while Pemfexy rose from $0.06 to $0.20 PMPM. Pemfexy had a 145.7% utilizer increase compared to a 9.6% decrease in Alimta utilizers. This shift may be driven by product preference due to ease of administration. Pemfexy is a ready-todilute liquid IV formulation that eliminates the reconstitution step required to prepare Alimta.
2022–2023 respiratory cancer Medicare components of change** Figure 47
Zepzelca Yervoy Opdivo Imfinzi
Tecentriq Keytruda
Medicaid deep dive
Non-Hodgkin lymphoma
Non-Hodgkin lymphoma (NHL) spend increased, making it the third most costly drug spend for Medicaid markets in 2023 (up from seventh in 2022). The PMPM trend increased 84% ($0.30 PMPM 2022 to $0.55 PMPM 2023) and contributed 8% to overall Medicaid cancer spend. Part of this increased spend was due to the impact of CAR T-cell therapies, such as Yescarta and Breyanzi.
Yescarta, Adcetris and Polivy were the top three spend drivers for NHL in 2023. Yescarta was the first CAR T-cell therapy to receive a second-line FDA indication in April 2022. Outpatient utilization changed from zero in 2022 to very low utilization in 2023; however, it still made the most significant contribution to Medicaid spend (PMPM $0.11 in 2023; 20.5% of NHL spend). At $476,222/claim, CAR T-cell therapy significantly impacts spend despite low utilization.
In April 2023, Polivy received approval as first-line therapy in combination with R-CHOP regimen for diffuse large B-cell lymphoma (DLBCL), marking nearly 20 years since the FDA approved a first-line treatment for this type of cancer. This approval likely contributed to the large change in PMPM spend ($0.02 PMPM in 2022 to $0.08 PMPM in 2023; +405.1%) and utilization (+580.7% claims).
Truxima PMPM decreased 26.7% despite having the fourth-highest PMPM for NHL in 2023, driven by decreased utilizers and claims. Notably, Ruxience utilizers and claims increased by 103%. Top
oncology spend by cancer type Figure 48
2022–2023
NHL Medicaid components of change** Figure 50
Female reproductive cancer spend by LOB
Figure 51
Female reproductive cancer
Female reproductive cancer spend increased across all lines of business (LOBs) in 2023 (+40.5% commercial, +15.5% Medicare, +65.8% Medicaid). Keytruda remained the top drug by spend for all LOBs at $0.48 PMPM commercial (+57.4%), $0.85 PMPM Medicare (+44.2%) and $0.19 PMPM Medicaid (+71.1%). Utilizers increased 50.9%, 33.1% and 50.7% in commercial, Medicare and Medicaid, respectively, driving spend.
Keytruda and Jemperli received expanded indications for endometrial cancer, which led to increased spend and utilization of both drugs. Jemperli spend was $0.04 PMPM in commercial and $0.12 PMPM in Medicare, all of which was new spend for female reproductive cancer.
Bevacizumab biosimilars Mvasi and Zirabev continued to gain market share in 2023. These two drugs combined made up 12% of commercial, 14% of Medicare and 11% of Medicaid. Increased biosimilar uptake helped offset trend, since these drugs have a lower annual cost per utilizer than Avastin.
Tivdak ranked among the top six drugs by spend in commercial and Medicaid. In commercial, PMPM doubled from $0.02 PMPM to $0.04 PMPM in 2023, driven by a 36.5% increase in utilizers. In Medicaid, PMPM had new spend of $0.03 PMPM in 2023. This trend may be attributed to results from the Phase 3 innovaTV 301, published in late 2023, which demonstrated treatment with Tivdak resulted in a 30% reduction in risk of death in recurrent or metastatic cervical cancer patients with disease progression on or after front-line therapy, compared with chemotherapy.
Female reproductive cancers commercial 2023 market share* Figure 52
Female reproductive cancers Medicare 2023 market share* Figure 53
Female reproductive cancers Medicaid 2023 market share* Figure 54
*Market share based on unique drug utilizers. Female reproductive cancers include cancers of the cervix, endometrium, fallopian tube, ovary, uterus, vagina and vulva.
Keytruda Mvasi Jemperli Zirabev Abraxane Doxil
Keytruda Mvasi Tivdak Libtayo Zirabev Abraxane
Keytruda Mvasi Zirabev Tivdak Jemperli Abraxane
Urinary system cancer spend by LOB Figure 55
Urinary system cancer
For commercial and Medicare, PMPM of urinary cancer drugs increased 20.2% and 38.3%, respectively, in 2023. PMPM increases were driven by an increased number of utilizers, 12.2% for commercial and 13.6% for Medicare. Conversely, PMPM decreased 23.9% for Medicaid, and the number of utilizers in this category decreased 27.3%.
Keytruda and Padcev were among the top drug drivers of spend for commercial and Medicare, together contributing 17.7% of the urinary cancer drug trend for commercial and 19.5% for Medicare. For Medicaid, Padcev went from zero to $0.04 PMPM as utilizers increased 191.7%. In 2023, the combination of Keytruda and Padcev received expanded indication for urothelial cancer, leading to increased spend and utilization.
While Keytruda and Opdivo both drove increased PMPM for commercial and Medicare, spend decreased in the Medicaid population by 21.6% and 44.3%, respectively, due to lower utilization. Trodelvy accounted for 8% of Medicaid spend in urinary cancer, up from 0%. Currently under accelerated approval for locally advanced or metastatic urothelial cancer, the upward trend may reverse as a result of the TROPiCS-04 confirmatory trial in which the primary endpoint of overall survival was not met, and more deaths occurred in the Trodelvy arm.9
In the Medicare population, Jelmyto experienced a 3314.8% increase in PMPM, predominantly due to an increase in utilization of more than 5000%. The significant increase in utilization of Jelmyto may be due to a shortage of the standard treatment for bladder cancer, Tice BCG.
Urinary system cancers Medicare 2023 market share* Figure 57
Keytruda Opdivo Padcev Yervoy Jelmyto Bavencio
Keytruda Opdivo Padcev Trodelvy Bavencio Tecentriq
Keytruda Opdivo Padcev Yervoy Bavencio Tecentriq
Ophthalmic injections
Ophthalmology continues to impact overall spend and PMPM within commercial and Medicare. Compounded bevacizumab (Avastin) remains the most cost-effective drug in this category, while higher-cost Vabysmo is slowly adding to the landscape. The market share for bevacizumab within both lines of business (LOBs) balances the incremental costs driven by Eylea and Vabysmo. Biosimilar uptake has made small gains in this category, but the ranibizumab biosimilars haven’t made the impact seen with other biosimilars. Additionally, compared to compounded bevacizumab, the biosimilars are not the least costly products in this category. The expected aflibercept (Eylea) biosimilars could be the next game changer in this category.
The overall trend in commercial and Medicare LOBs shows an increase in costs $0.24 PMPM and $1.99 PMPM, respectively, over the last five years. Utilization for wAMD and DME, the inclusion of the treat and extend therapies, and comparatively priced biosimilars to the originator products continue to drive up costs in this category.
Within commercial, Eylea is driving the cost per utilizer and PMPM. Eylea had a 7.5% increase in PMPM from the previous year and continues to gain utilization in the commercial LOBs.
The Medicare trend depicts a 16.9% increase in PMPM from the previous year. Vabysmo and biosimilar strategies utilizing Cimerli contributed to this trend. The ophthalmic category is second only to oncology and makes up 11.6% of overall spend, which illustrates the impact the ophthalmic injections have on trend (Pg. 10, Fig. 14).
Multiple sclerosis
Multiple sclerosis (MS) ranks among the top 10 highest spend categories by PMPM for all lines of business (LOBs). Notably, it is the thirdhighest PMPM spend category for commercial (Pg. 8, Fig. 10). Across all LOBs, PMPM spend increased in 2023. Ocrevus accounted for more than 70% of MS PMPM spend for all LOBs. Since 2019, the PMPM spend has risen every year except for a single-digit trend reversal for Medicaid (-1.1%) and Medicare (-5.1%) in 2021. Tysabri ranks a distant second behind Ocrevus, with just under 30% of PMPM spend.
For commercial, the MS category accounted for 8% of total PMPM spend and saw an 11.1% trend (Pg. 8, Fig. 10). This trend was largely driven by a 7.2% rise in cost per claim and a 3.6% increase in claims volume. Commercial had the highest PMPM spend and highest cost per claim at $3.91 and $26,755, respectively.
The MS category for Medicare accounted for 2.2% of total PMPM spend and saw a 13.1% trend (Pg. 10, Fig. 14). The PMPM spend increase was driven by a 6.5% increase in utilizers and a 6.2% increase in cost per utilizer.
For Medicaid, the MS category accounted for 5.4% of total PMPM spend and saw an 18.4% trend (Pg. 12, Fig. 18). The significant increase in PMPM spend in 2023 was driven by a 42.9% increase in utilization, though this increase in PMPM spend was dampened by a decrease in cost per utilizer of 17.1%. Cost per utilizer decreased due to increased utilization of lowercost biosimilars Truxima (+32.6%) and Ruxience (+94.5%).
2023 % of medical drug spend Figure 65
2023 cost per claim Figure 66
Immune globulin
The immune globulin category ranks in the top five by PMPM spend for all lines of business (LOBs), accounting for 5.9% of total PMPM spend in commercial, 4.3% in Medicare and 4.5% in Medicaid (Figs. 10, 14, 18). The cost per claim for commercial LOB is 55% higher than Medicare, mainly due to drug mix, varied indications and different reimbursement strategies for both LOBs.
Commercial saw an 8.2% overall trend, most of which stemmed from increased utilization. This is not typical, as immune globulin trend has been more than 10% in the last couple of years in commercial. Spend from highly utilized immune globulin products Gammagard and Privigen increased 11.8% and 14.5%, respectively.
We saw a double-digit trend in Medicare, also driven by Gammagard in the IV space with a 19.8% increase in PMPM and Hizentra with a 21.1% increase in PMPM in the SQ category.
The Medicaid trend has been relatively flat, resulting from utilization increases offset by decreases in cost per claim. Medicaid saw increases in utilization for Gammagard (+17.5%), Gamunex-C (+14.2%) and Privigen (+27.7%) and noted decreases in utilization for Hizentra (-19.7%) and Octagam (-17.7%).
2023 % of medical drug spend Figure 69
2022–2023 PMPM trend Figure 71
Hematology*
Hematology continues to be a category to watch. All lines of business (LOBs) saw an overall increase in spend in 2023, with a 27% increase in Medicare and commercial that is largely attributable to myasthenia gravis. For many years, Soliris accounted for myasthenia gravis spend, with a small percentage attributed to rituximab; however, the current trend increase for both LOBs was driven by the newer products Vyvgart and Ultomiris, both up 250% in Medicare, and 276% and 444% for these drugs, respectively, in commercial.
Medicaid saw a 20.5% trend increase driven by treatments for atypical hemolytic uremic syndrome (aHUS) with large trend increases in Ultomiris (105.3%) and Soliris (61%). After two years of negative trend in Medicaid, spend in the hematology: NMOSD category jumped 276.3% due to Uplizna trend increase. Uplizna also saw a 34.5% trend increase in commercial but decreased 24% in Medicare.
The hematology: myasthenia gravis therapy category broke into the top 10 Medicare therapies for the first time with a PMPM of $1.21 (Pg. 10, Fig. 14). This was the largest contributor to the overall hematology spend of $2.76 PMPM for Medicare. The Medicare cost per claim was approximately half that of commercial and Medicaid.
*Hematology drugs included in this report are Adakveo, Nplate, Panhematin, rituximabs, Soliris, Ultomiris, Uplizna and Vyvgart. Rituximab products were only included when used for hematologic indications.
2023 cost per claim Figure 74
2023 % of medical drug spend Figure 73
Enzyme replacement therapy
Enzyme replacement therapy was the sixthhighest PMPM spend category for Medicaid (Pg. 12, Fig. 18) and ranked 11th in commercial. This category has minimal spend ($0.01 PMPM) in Medicare. For commercial and Medicaid, PMPM spend increased 8.8% and 14.6%, respectively. Fabrazyme for Fabry disease had the highest PMPM spend, accounting for 24% of commercial spend and 29% of Medicaid spend. An additional trend driver in commercial was Nexviazyme for late-onset Pompe disease, which increased 281% in 2023. Crysvita had the second-highest spend in Medicaid at $0.25 PMPM; however, trend remained flat year over year.
For commercial, the enzyme replacement therapy category accounted for 1.7% of total PMPM spend and saw an 8.8% year-over-year trend. This trend was largely driven by a rise in cost per claim of 11% compared to 2022. PMPM spend has been consistently trending upward since 2019 and forecasts indicate that spend will continue to increase 11.2% over the next three years.
For Medicaid, the enzyme replacement therapy category accounted for 4.9% of total PMPM spend and saw a 14.6% trend (Pg. 12, Fig. 18). Unlike commercial, Medicaid PMPM has consistently increased by roughly 14.4% each year over the past few years. The increase in PMPM spend in 2023 was driven by a 20.2% increase in utilization, though this increase in PMPM spend was dampened by a decrease in cost per utilizer of 7.3%.
Pegfilgrastim
Oncology biosimilar trends
Biosimilar market share continued to increase across several oncology categories.
Pegfilgrastim
Neulasta’s market share decreased for all lines of business (LOBs). While Neulasta is still a top 10 drug by spend for commercial and Medicaid, it no longer is for Medicare. The decrease in market share was offset by a large increase of Fulphila across all LOBs. Additionally, Ziextenzo market share dropped significantly due to shortage and availability issues.
Filgrastim
In commercial, Neupogen market share decreased, while Zarxio and Granix share remained largely stable and Nivestym saw significant increases. Across Medicare and Medicaid, market share for all products remained mostly consistent.
Rituximab
Across LOBs, Rituxan market share continued to slowly erode, while the biosimilars increased modestly.
Trastuzumab
Across LOBs, Herceptin market share continued to decrease, while Trazimera share continued to steadily increase. Additionally, Ogivri market share increased in commercial, and Ontruzant increased in Medicare.
Bevacizumab
Across LOBs, Avastin market share continued to decrease to less than 5% and was offset by increases in Mvasi and Zirabev.
Bevacizumab market share Figure 82
Trastuzumab market share Figure 81
Neulasta Fulphila Udenyca Ziextenzo Nyvepria Rituxan/Rituxan Hycela Ruxience Truxima Riabni
Avastin Mvasi
505(b)(2)
New in this year’s report is a breakdown of drugs approved via the 505(b)(2) pathway. Noninterchangeable or 505(b)(2) generic products may be approved via new drug approval (NDA) under the FDA’s 505(b)(2) pathway where the innovator product’s data can be referenced for the approval. CMS has taken the approach of issuing a distinct HCPCS code for each 505(b)(2) NDA approved drug.
In all lines of business (LOBs), the overall PMPM trend (which includes innovators and 505(b)(2) agents) decreased as a result of lower spend for innovator products. Spend on the 505(b)(2) agents increased by 26.5%, 92% and 38.5% for commercial, Medicare and Medicaid, respectively.
Bendeka (bendamustine) was the top 505(b)(2) drug by PMPM spend across all LOBs in 2023. Commerical PMPM was $0.09, down from $0.10 in 2022. A decrease in utilizers (-16.2%) offset an increase in cost (4.5%). In Medicare, PMPM rose from $0.24 to $0.26 as utilizers grew by 15.4%. Medicaid saw similar trends, with Bendeka PMPM increasing from $0.03 to $0.04 as a result of a 43.8% increase in utilizers.
The top 505(b)(2) drugs for commercial were Bendeka, Kyleena (levonorgestrel), Pemfexy (pemetrexed), Onivyde (irinotecan) and Liletta (levonorgestrel). In Medicare, the top drugs were Bendeka, Pemfexy, Onivyde, Jelmyto (mitomycin) and Cancevi (leuprolide). Top Medicaid drugs were Bendeka, Liletta, Kyleena, Pemfexy and Belrapzo (bendamustine).
Medical pharmacy management
Payer survey
Respondent sample Figure 87
Respondent plan size Figure 88
30 payers (21 with Medicare lives)
76.2M medical pharmacy lives (national, regional and local/state)
Geographic dispersion of lives Figure 89
73% pharmacy directors, VPs, chief pharmacy officers
27%
C-suite, medical directors, clinical managers
Utilization management strategies
Utilization management of medical drugs is top of mind for payers. Of the payers surveyed, 73% (n = 22) said they are currently performing edits on claims for medical drugs. Top claims edits that payers have or would like to have implemented are for dose (i.e., number of units per administration) and authorization to claim match (95% and 86%, respectively). The majority of payers (78%) apply medical claims edits to all providers, although 15% have some form of “gold carding” exemption in place. The gold card process exempts providers from prior authorization requirements based on previous approval metrics. In addition to medical claims edits, 80% of payers indicated they currently manage, or are considering managing, complex dosing via post-service claims edits.
Payers are interested in reviewing treatment regimens across the medical and pharmacy benefit. Almost all payers surveyed (97%) indicated that monitoring medical and pharmacy claims for drug duplicates is of interest, although only 67% of plans are currently monitoring for these duplicates. As plans work to gain a holistic view of drug spend across benefit types, 80% of payers stated they would be interested in monitoring treatment (such as receiving oral oncology drugs on the pharmacy benefit and infused chemotherapy on the medical benefit) via reports that span across the medical and pharmacy benefit.
Cell and gene therapy
Cell and gene therapy (CGT) is top of mind for health plans due to the high cost of these treatments and the uncertainty around identifying patients who would qualify for these treatments. For those excluding gene therapies, affordability and lack of clinical guidance are the biggest factors. It is difficult to report on claims for these medications as CGT is typically given during an inpatient hospital stay and is billed as part of a bundle payment. Most plans surveyed (93%) are managing gene therapies. Top management strategies include reinsurance/stop loss (82%), value-based agreements (61%), and single-case agreements (61%). Just more than half (54%) of plans indicated that total cost of care or cost effectiveness was the most important aspect of real-world evidence used to guide decisionmaking. Plans surveyed did not have a consensus on gaps in patient care journey or ways to monitor outcomes, highlighting the continued uncertainty around managing this class of medications.
In 2023, four gene therapy medications were approved that are in the top 10 highest-cost drugs on the market. Casgevy and Lyfgenia for sickle cell disease, Elevidys for Duchenne muscular dystrophy, and Roctavian for hemophilia A. With a robust pipeline of cell and gene therapy, and cost of these therapies continuing to rise, this therapeutic category will be one to watch in years to come.
CAR T-cell therapy
CAR T-cell therapies continue to be an area of concern for health plans due to high cost and the potential for these therapies to shift from inpatient to outpatient administration. Most plans surveyed (87%) require prior authorization/ medical necessity review for CAR T-cell therapies with 83% consulting a specialist, whether inside or outside of their organization. The main concerns around a shift to outpatient administration are increased cost and payment considerations if patient needs to be admitted, as well as safety and and quality of care in the outpatient setting.
Reimbursement for CAR T-cell therapies varied between plans. The majority (52%) had drug product and associated care (e.g., inpatient, ICU) reimbursed separately by individual Current Procedural Terminology (CPT) code via code via the medical benefit.
Outcomes tracking is another area where there was no consensus among plans surveyed. Only half of plans are currently tracking outcomes for some or all FDA-approved CAR T-cell therapies. The largest challenge plans noted was how to track member outcomes. Also complicating outcomes tracking were understanding how to interpret outcomes, obtaining adequate information to fulfill financial agreements and patient portability across plans.
CAR T-cell therapies: main concern for outpatient SOS shift Figure 105
Genomic testing management concern Figure 107
Oncology focus topics
Genetic/genomic testing is a concern for 70% of plans. Genetic/genomic testing is defined as testing that involves examining an individual’s genes or entire genome to identify gene alterations or mutations for diagnosis or treatment selection. Most plans (67%) have prior authorization requirements in place for genomic sequencing (testing that is performed on the tumor tissue to look for mutations). In 2023, drugs such as Keytruda and Jemperli received expanded indications where labeling references an FDA-approved companion diagnostic test. As more targeted therapies continue to come to market, it is anticipated that genomic/genetic testing will be a topic of interest in the oncology space in the coming years.
Regimen-based review strategies implemented Figure 108
No, but would be preferred
Yes, review at regimen level
Yes, currently implementing
No, prefer drug-bydrug reviews
Regimen-based review strategy challenges Figure 110
Appendix
year’s report includes drivers and dampeners. *Trend driver rank is based on total change from 2022–2023. Medicare top 25 drug PMPM spend 2022–2023 Figure 117
2023
Tepezza Spinraza Exondys 51 Gamifant
Commercial Figure 120
Gamifant
Amondys 45
Zolgensma
Givlaari
Reblozyl
$1,276,988 $1,396,686
$4,641,873 $1,385,381
$970,536 $1,337,526
$2,089,583 $1,516,595
$608,066 $433,001
$160,229 $190,343
Other $267,341 $466,481
*Rare disease drugs included in this report are Amondys 45, Amvuttra, Evkeeza, Exondys 51, Gamifant, Givlaari, Luxturna, Onpattro, Oxlumo, Radicava, Reblozyl, Spinraza, Tepezza, Viltepso, Vyondys 53, Xenpozyme and Zolgensma.
Amondys 45 Zolgensma Givlaari Reblozyl Other
Gammagard Liquid Gamunex-C/Gammaked Privigen Octagam Hizentra Gammaplex
Commercial Figure 123
$59,320
*Immune globulin drugs included in this report are Asceniv, Bivigam, Carimune, Cutaquig, Cuvitru, Gammagard
Gammaplex, Gamunex-C/Gammaked, Hizentra, Hyqvia, Octagam, Panzyga, Privigen and Xembify.
2023 market share trends: BDAIDs: Crohn’s disease/ulcerative colitis*
*BDAIDs: Crohn’s/UC drugs included in this report are Avsola, Cimzia, Entyvio, Inflectra, Remicade, Renflexis, Rituxan, Ruxience, Simponi Aria, Skyrizi, Stelara IV/SQ and Truxima.
Orencia Actemra Simponi Aria Remicade Cimzia
Commercial Figure 129 Medicare Figure 130 Medicaid Figure 131
*BDAIDs: Rheumatoid Arthritis drugs included in this report are Actemra, Avsola, Cimzia, Inflectra, Orencia, Remicade, Renflexis, Rituxan, Ruxience, Simponi Aria and Truxima.
Commercial Figure 132
Medicare Figure 133
Medicaid Figure 134
Ultomiris Soliris Nplate Vyvgart Uplizna Adakveo Other
*Hematology drugs included in this report are Adakveo, Nplate, Panhematin, rituximabs, Soliris, Ultomiris, Uplizna and Vyvgart.
2023 market share trends: oncology support: long-acting, colony-stimulating factors
Neulasta Fulphila Udenyca
market share trends: ophthalmic injections*
Commercial Figure 141
Medicare Figure 142
Medicaid Figure 143
Eylea Vabysmo Lucentis Avastin Ozurdex Cimerli Other
*Ophthalmic injections included in this report are Avastin, Beovu, Byooviz, Cimerli, Durysta, Eylea, Iluvien, Lucentis, Ozurdex, Syfovre, Vabysmo and Yutiq.
2023 commercial top 25 drug PMPM spend by site of service Figure 144
Due to rounding, totals may not add up accurately.
Due to rounding, totals may not add up accurately.
2023 biosimilar market share*
Bevacizumab drug group** Figure 147
Trastuzumab drug group Figure 148
Hylecta
Rituximab drug group** Figure 149
Hycela
Infliximab drug group Figure 150
*Market share based on unique drug utilizers. **Bevacizumab and rituximab market share reflects oncology indication only. Totals may not add to 100% because drugs with immaterial market share are excluded from the graphics.
Remicade
2023 biosimilar market share*
Pegfilgrastim drug group Figure 151
Neulasta
Fulphila
Udenyca
Ziextenzo
Nyvepria
Filgrastim drug group Figure 152
Neupogen Zarxio
Nivestym Releuko
Epoetin alfa drug group Figure 153
*Market share based on unique drug utilizers. Totals may not add to 100% because drugs with immaterial market share are excluded from the graphics.
administration, intravenous infusion technique; each additional sequential infusion (different substance/drug), up to 1 hour (List separately in addition to code for primary procedure)
Intravenous infusion, for therapy, prophylaxis, or diagnosis; additional sequential infusion of a new drug/substance, up to 1 hour (List separately in addition to code for primary procedure)
Glossary and references
aHUS atypical hemolytic uremic syndrome
AI autoimmune
AS................................................................................................................................................................................. anklosying spondylitis
ASP average sales price
AWP....................................................................................................................................................................... average wholesale price
BDAIDs biologic drugs for autoimmune disorders
CAR T chimeric antigen receptor T-cell therapy
COVID-19................................................................................................................................................... coronavirus disease of 2019
Crohn’s/UC Crohn’s disease / ulcerative colitis
DME diabetic macular edema
Dosing number of units/claim
ESA erythropoiesis-stimulating agent
FDA ............................................................................................................................................... U.S. Food and Drug Administration
GCSF granulated colony-stimulating factors
HCPCS Healthcare Common Procedure Coding System
HER2 human epidermal growth factor receptor 2
HOP hospital outpatient
Inflation ................................................................................................................ASP/AWP price changes on a per unit basis
IV intravenous LOB line of business
MG myasthenia gravis
MS multiple sclerosis
NMOSD .......................................................................................................................... neuromyelitis optica spectrum disorder
NSCLC non-small cell lung cancer
PMPM per member per month
PS................................................................................................................................................................................................................... psoriasis
psoriatic arthritis RA ...................................................................................................................................................................................... rheumatoid arthritis Rare AI rare autoinflammatory conditions
Reimbursement changes in the level of provider reimbursement, provider mix and site-of-service mix (relative to ASP)
SLE /lupus ......................................................................................................................................... systemic lupus erythematosus
SQ/SC subcutaneous
UC ulcerative colitis
Utilizers number of unique utilizers
WAMD wet age-related macular degeneration
1 2, 6 IPD Analytics. FDA Novel Drug Approvals - 2023 Year in Review. Published March 2024
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4 6 Pneumococcal vaccination: Who and when to vaccinate | CDC. https://www.cdc.gov/vaccines/vpd/pneumo/hcp/who-when-to-vaccinate.html
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6 20 Breast cancer: screening. Published April 30, 2024. https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/breast-cancer-screening
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8 20 Gradishar WJ, Moran MS, Abraham J, et al. National Comprehensive Cancer Network (NCCN) clinical practice guidelines in oncology. Breast Cancer Version 3.2024. Retrieved June 29, 2024 from https://www.nccn.org/professionals/physician_gls/pdf/breast.pdf.
9 25 Clarke H. Sacituzumab govitecan falls short in phase 3 trial for metastatic urothelial carcinoma. Urology Times. https://www.urologytimes.com/view/sacituzumabgovitecan-falls-short-in-phase-3-trial-for-metastatic-urothelial-carcinoma. Published May 31, 2024.
