Pharmacy Benefit Spending on Oral Chemotherapy Drugs

BACKGROUND: Pharmacy benefits have historically excluded injectable drugs,resulting in coverage of injectable drugs under the medical benefit. High-costbiologics and other new drug therapies are often injectables and therefore havenot presented cost threats to pharmacy benefits. The U.S. Food and Drug Administration approval of capecitabine, an oral form of fluorouracil, in 1998,and imatinib mesylate in oral dose form for chronic myeloid leukemia, in 2001,signaled a new period in budget forecasting for pharmacy benefits, particularly for small, self-insured employers for whom a drug with a cost of $25,000 peryear of therapy for 1 patient could increase total pharmacy benefit costs by 10% or more. OBJECTIVES: To quantify the actual relative costs of the oral chemotherapydrugs in pharmacy benefits in 2006 and identify the history of spending onoral chemotherapy drugs relative to total pharmacy benefit spending for small, self-insured employers over the 4.5 years through May 2006. METHODS: Administrative pharmacy claims from the database of a pharmacy benefits manager (PBM) for approximately 500,000 members of small, self-insuredemployer plans were used to calculate the net plan cost of oral chemotherapy drugs relative to total drug benefit costs for the period January 1, 2002, through May 31, 2006. Current costs for oral chemotherapy drugs for small employers were compared with an insured health plan of approximately the same numberof members for dates of service January 1, 2006, through May 31, 2006. RESULTS: This descriptive analysis found that oral chemotherapy drugs represented 0.27% of total drug benefit costs, or approximately $0.08 per member permonth (PMPM) for small, self-insured employers in 2002, rising linearly to 0.73%,or approximately $0.24 PMPM in the first 5 months of 2006. Members in pharmacy benefit plans sponsored by small employers paid an average 6.9% cost share fororal chemotherapy drugs in 2006, nearly identical to the average 8.5% paid by members of an insured health plan of similar size in total membership, versus 26.9% average cost share for all drugs. Imatinib mesylate accounted for 45% oftotal spending on oral chemotherapy agents in 2002 versus 40% in 2006. CONCLUSIONS: Spending on oral chemotherapy drugs as a proportion of total pharmacy benefit costs has more than doubled, from about 0.3% in 2002 to 0.7%in 2006. For small, self-insured employers, this represents a nearly 3-fold increasein spending, from about $0.08 PMPM in 2002 to about $0.24 PMPM in 2006.