Highmark’s Strategy to Contain Drug Costs Includes an Increasing Number of Outcome-Based Contracts

Pharmaceutical manufacturers and payers have developed a number of agreements under which reimbursement is contingent on specific outcomes over the last few years. The main challenge for both parties to these agreements is identifying and measuring outcomes.

Highmark has been among the industry leaders in entering outcomes-based agreements and recently developed a contract for UCB’s medication CIMZIA® (certolizumab pegol). As the fourth-largest overall Blue Cross Blue Shield-affiliated organization, Highmark and its Blue-branded affiliates cover the insurance needs of more than 5.6 million members in Pennsylvania, Delaware, and West Virginia.

CIMZIA is a tumor necrosis factor blocker that is prescribed for adult patients with chronic inflammatory conditions that include Crohn’s disease, plaque psoriasis, psoriatic arthritis, rheumatoid arthritis, non-radiographic axial spondyloarthritis, and ankylosing spondylitis.

The outcomes-based agreement for the CIMZIA lyophilized powder healthcare professional administered formulation applies to all commercial members in Highmark’s national and core health insurance markets in Pennsylvania, West Virginia, and Delaware. Approximately 380 Highmark members have prescriptions for CIMZIA.

Highmark previously entered into value-based contracts with pharmacy manufacturer Takeda targeting autoimmune diseases, as well as with Boehringer Ingelheim and AstraZeneca for the treatment of COPD and diabetes, respectively.

Takeaway: Highmark continues to include outcome-based contracts in its strategy to address rising drug costs and enhance its members’ health outcomes