Navigating Pharmacy Benefits in 2023 and Beyond: Complex and Costly Medication Trends

How Gene Therapy and Weight-Loss Medications Impact Plan Design

In the world of health care, rapidly advancing technology is transforming the quality of life for many patients. Medications and treatments that once seemed out of reach are now a reality, and pharmacy benefit professionals must now consider and evaluate these new advances. 

Two of the latest trends in pharmaceuticals include gene therapies and a rising demand for GLP‑1 drugs for weight loss. 

How do employers, brokers, and consultants navigate these complex and costly medication trends when putting together pharmacy benefit plans? 

If you have clinicians in then room when you are talking about your second highest budget line item in your company — health care benefits — you will be miles ahead of the competition that doesn’t have clinical expertise in the room,” advises Erin Albert, MBA, PharmD, JD, a pharmacist working with Mark Cuban to lower US prescription drug costs. It is monumentally valuable to find broker advisors who have full-time clinicians who can dig through the claims and study patient care and history.” 

Diving into the details of gene therapy and weight-loss medications shows exactly why brokers and employers need clinicians involved in making pharmacy benefit plan decisions. 

Albert and Eric Barker, RPh, Chief Growth Officer, True Rx Health Strategists, recently explored these topics and other trends in a webinar, Health Care Trends to Watch in 2023. We’ve summarized several of their insights in this blog. 

Gene Therapy: Revolutionary Treatments and Eye-Popping Price Tags 

Recently, the FDA approved three new gene therapies – each with record-breaking prices. These include: 

  • Hemgenix is a one-time treatment for patients with moderate to severe Hemophilia B and costs $3.5 million. Clinical trial data suggests a single dose could provide adequate protection from uncontrolled bleeding for eight years. Currently in the US, the treatment of an adult with hemophilia B averages $700,000 – 800,000 per year, according to Glenn Pierce, vice-president of the World Federation of Hemophilia.
  • Skysona, which treats a rare neurological disorder, cerebral adrenoleukodystrophy (CALD), is priced at $3 million per treatment.
  • Zynteglo was approved as a one-time treatment for beta thalassemia, a type of inherited blood disorder that requires regular red blood cell transfusions. The price is $2.8 million. 

Gene therapies overall are very exciting and equally terrifying to plans,” says Albert. Exciting in that they could be revolutionary in curing some diseases; terrifying due to their price tags.” 

The Takeaway for Benefits: Plan Ahead with Clinicians by Your Side 

According to Albert, 20 to 25 new gene therapies are in the pipeline and coming before the FDA for approval in the next few years. With a self-funded plan, a stop-loss policy would typically pick up the first treatment, but what happens if a patient needs a second gene-therapy treatment? 

Having a thoughtful conversation now with benefits consultants and clinicians can help you evaluate these therapies and decide on a strategy before a claim for gene therapy hits your plan. 

Weight-Loss Drugs: How GLP‑1 Meds Fit in Overall Health 

With the rise in popularity of GLP‑1 drugs for weight loss, such as Ozempic, brokers and employers may be wondering if they should offer a weight-loss category in their formulary list. 

For some patients, a GLP‑1 might help them jumpstart their journey toward better health,” says Barker. Significant weight loss lowers the chances of stroke, dialysis, and other complications….The question is what happens when you are not on the medication.” 

The Takeaway for Benefits: Make Weight-Loss Medications Part of an Overall Wellness Plan 

Barker advises CEOs and benefit decision-makers to implement other benefits that build on the initial weight loss and give employees the tools for a healthy lifestyle. 

For example, pay for your employees to have a consultation with a nutritionist,” says Barker If you’re going to cover weight-loss drugs, back it up with something else that really helps people understand lifelong health habits.” 

You can learn more about gene therapy, weight-loss drugs, and other trends in the True Conversations webinar, Health Care Benefits to Watch in 2023.

Consult with a Pharmacist Strategist for Your Pharmacy Benefits Plan

If you’re a health care benefits broker, consultant, or an employer who wants to discuss pharmacy benefit solutions with a pharmacist strategist, contact us at hello@​truerx.​com to arrange a meeting.