Highmark Develops Initiatives to Control Drug Spending

Highmark has recently forged outcomes-based contracts for the treatment of several high-cost, chronic health conditions, including COPD, diabetes and inflammatory bowel disease.

As the fourth-largest overall Blue Cross Blue Shield-affiliated organization, Highmark Inc. and its Blue-branded affiliates cover the insurance needs of 4.5 million members in Pennsylvania, Delaware, and West Virginia. Its diversified businesses serve group customer and individual needs across the United States through dental insurance, vision care and other related businesses.

In another initiative to control its drug spending, Highmark announced a new partnership focused on the treatment and management of hemophilia. The partnership aims to ensure that members receive hemophilia drugs from organizations that meet rigorous performance standards and to reduce drug waste and fraud that increases costs.

Beginning in January of 2020, Highmark members will receive hemophilia drugs exclusively from three providers: Option Care Health, Soleo Health and the Hemophilia Center of Western Pennsylvania.

Hemophilia A is the most common type of hemophilia and is caused by deficient or dysfunctional clotting factor VIII. Although hemophilia A is usually inherited, about 30% of cases are caused by a spontaneous mutation in the person’s own genes. 

Hemophilia A affects about 1 in 12,000 people and is diagnosed by taking a blood sample and measuring the level of factor activity in the blood. Hemophilia A is diagnosed by testing the level of factor VIII activity in the blood. 

But according to a 2015 Express Scripts report, the drugs to treat hemophilia cost more than $270,000 annually on average. For patients who have complications from their disease, the annual price can climb above $1 million. There are approximately 30 different hemophilia drugs available in the U.S., with another 20 in development. They are typically biologics, with no current biosimilars available.

Highmark health plans have approximately 190 members who have been diagnosed with hemophilia. Highmark spends around $80 million annually on care for hemophiliacs, with about 90 percent of that total attributed to pharmacy costs.

Highmark selected the participants for its hemophilia partnership through a competitive RFP process. The new program complements Highmark’s Hemophilia Member Care Program. Through the program, Highmark identifies members with hemophilia based on risk and links them to a multidisciplinary care team that includes a nurse, pharmacist, physician, other clinicians and behavioral health providers. Members receive an individualized care plan and education that helps them better understand and manage their condition


Takeaway: Highmark also has outcomes-based contract with Boehringer Ingelheim for Jardiance®, and AstraZeneca for the respiratory medicine SYMBICORT®.