Amgen Introduces New Value-Based Pharmacy Benefits Insurance Provision for U.S. Staff Members

In 2017, Amgen is introducing an innovative new value-based pharmacy benefits insurance provision for U.S. staff members.  The coverage ensures that any U.S. staff member who is prescribed a clinically appropriate biologic medicine will pay the same out-of-pocket cost as a staff member who has the same condition, but does not require a biologic. The benefit was designed to eliminate concerns about cost-related barriers to essential biopharmaceuticals, which play an increasingly prominent role in the treatment of patients with serious illness.

“Amgen is adopting a value-based pharmacy benefit to ensure our staff do not have to pay more out-of-pocket solely because they have failed other treatments and now require a biologic, or because they have a genetic condition requiring a biologic as first-line therapy,” said Lori Johnston, Senior Vice President of Human Resources at Amgen. “This approach helps assure that staff members and their families enrolled in our plan do not face barriers to the best therapy for their unique needs. We encourage other employers to consider value-based insurance design rather than a cost driven formulary policy. This will ensure equity and comparable clinical benefits for their employees.”

Barriers to access are, in part, due to current U.S. formulary designs, which frequently assign patients high co-insurance rates (up to 50 percent of the drug cost) for high-cost drugs such as biologics (often referred to as “specialty drugs”).  This can impose an excessive financial burden on certain patients with serious illnesses. Additionally, patients who are clinically ineligible for, or do not respond to lower-cost first-line therapies and require biologics, often are subject to substantially higher levels of out-of-pocket cost. In some cases, this leads to patients failing to take their medicines and thus, poor outcomes. Value-based insurance design principles aim to remove barriers to medically necessary care by reducing out-of-pocket costs.  

To ensure that Amgen staff and their families have affordable access to clinically necessary medicines, Amgen supports the “dynamic” cost-sharing strategy for specialty medicines recently proposed by the University of Michigan Center for Value-Based Insurance Design []. This approach to the pharmacy benefit acknowledges that many patients with chronic conditions require more than one medicine to produce desired outcomes. Amgen’s new value-based provision will lower cost-sharing for staff members enrolled in its plan and who follow required clinical steps to manage their clinical conditions.  If a staff member requires a biologic therapy and takes proper steps to confirm that it is the most appropriate treatment, he or she would pay no more than a fixed co-payment.