Increased Out-Of-Pocket Expenses May Negatively Influence Arthritis Treatment

Prime Therapeutics (Prime) announced the results of its study, "Association Between Tumor Necrosis Factor (TNF) Blocker Out-of-Pocket (OOP) Expense and Member Decline to Fill Rate". The study assessed the association between decline-to-fill rates as they relate to out-of-pocket expense for members initiating TNF-blocker therapy for the treatment of inflammatory conditions such as rheumatoid arthritis. The use of TNF blocker agents to treat rheumatoid arthritis has been increasing among the aging U.S. population and treatment for the disease is becoming more and more costly.

Because of Prime's close working relationship with many large health plans, Prime is uniquely positioned to analyze both pharmaceutical and medical data to closely monitor drug safety, effectiveness, costs and prescribing practices. Through the evaluation of pharmacy claims of 4.4 million members from four major Blue Cross and Blue Shield Plans between July 2006 and June 2007, Prime was able to determine that members with an out-of-pocket cost greater than $250 were 4.6 times more likely to decline to fill their initial TNF-blocker medication.

In determining this, Prime found that more than six of seven members initiating TNF-blocker therapy had a per-claim, out-of-pocket expense of $100 or less with a low decline to fill rate of one in 50. The study also found that this decline to fill rate increased to at least one out of every 10 members when the out-of-pocket expense was $251 to $500 and grew to one out of every 5 when members paid the entire cost of greater than $1000. Members generally need to pay approximately $250 when they have a 20% coinsurance pharmacy benefit and they would have to pay the entire cost early in the year when their pharmacy benefit is a consumer directed healthcare product.

"From our findings, we believe that members who have an out of pocket expense of less than $100 per prescription fill are more likely to initiate treatment," said Patrick Gleason, PharmD, Director of Clinical Outcomes Assessment at Prime. "We also believe that the $250 out-of-pocket rate is an important value, and one that insurers should give consideration to, as it represents the expected out-of-pocket cost for members with a 20 percent co-insurance benefit."