Trends in List and Net Prices of Self-administered Systemic Psoriasis Therapies Manufactured by US-Based Pharmaceutical Companies

Abstract

This economic evaluation reviews the trends in list and net price data from SSR Health for the 2007 to 2019 period of self-administered systemic psoriasis medications manufactured in the United States.

Systemic psoriasis therapies are among the costliest drugs prescribed by dermatologists, and list prices of many of these drugs have increased over time.¹ However, list price alone gives an incomplete picture of true treatment costs, as pharmaceutical companies provide discounts to payers (rebates) and other offsets, such as copay assistance, which affect the net price of these drugs. We describe 2009 to 2019 trends in list and net prices for self-administered psoriasis therapies manufactured by companies publicly traded in the United States.

Methods

We obtained 2007 to 2019 list and net price data from the investment firm SSR Health for self-administered psoriasis therapies available in the United States by January 1, 2019 (Table).² This study was not subject to institutional review board review because no human data were used.

Table. Summary List Price, Net Price, and Discount Data for Initial Year of Therapy for an 80-kg Patient for Self-administered Systemic Psoriasis Therapies.

Variable	Drug
	Etanercept	Adalimumab	Ustekinumab	Apremilast	Secukinumab	Ixekizumab	Brodalumab	Guselkumab	Certolizumaba
Date of FDA approval for psoriasis	Apr 2004	Dec 2008	Sep 2009	Sep 2014	Jan 2015	Mar 2016	Feb 2017	Jul 2017	May 2018
Mechanism of action	TNF I	TNF I	IL-12/23 I	PDE4 I	IL-17A I	IL-17A I	IL-17R I	IL-23 I	TNF I
Manufacturer (current)	Amgen	AbbVie Inc	Janssen Pharmaceutica	Amgen	Novartis	Eli Lilly and Company	Ortho Dermatologics Inc	Janssen Pharmaceutica	UCB (Union Chimique Belge)
List price, $b
In 2009 or first available data (y)	23 421 (2009)	21 402 (2009)	23 265 (2009)	20 451 (2014)	51 354 (2015)	63 767 (2016)	35 947 (2017)	58 940 (2017)	37 050 (2009)
2019	69 481	64 438	45 444	34 545	77 883	75 848	39 635	63 669	94 379
Annual mean change, %	12	12	7	11	11	6	5	4	10
Net price, $b
In 2009 or first available data (y)	18 687 (2009)	17 776 (2009)	17 540 (2010)	16 935 (2015)	41 284 (2016)	40 204 (2016)	22 110 (2018)	22 218 (2017)	22 181 (2009)
2019	43 910	39 751	25 189	23 727	35 290	31 272	17 692	34 999	48 193
Annual mean change, %c	9	9	5	10	−4	−7	−20	26	9
Average discount, %d
In 2009 or first available data (y)	20 (2009)	17 (2009)	24 (2010)	26 (2015)	33 (2016)	37 (2016)	45 (2018)	62 (2017)	40 (2009)
2019	37	38	45	31	55	59	55	45	49

Abbreviations: FDA, US Food and Drug Administration; IL, interleukin; IL-12/23 I, IL-12 and IL-23 inhibitor; IL-17A I, IL-17A inhibitor; IL-17R I, IL-17–receptor inhibitor; IL-23 I, IL-23 inhibitor; PDE4 I, phosphodiesterase-4 inhibitor; TNF I, tumor necrosis factor-alpha inhibitor; USD, US dollar.

^aCertolizumab was initially approved for the treatment of Crohn disease in 2008 and was approved for the indication of psoriasis in 2018. Certolizumab pricing reported in the Table is calculated using the primary FDA-approved psoriasis dosing of 400 mg every other week. Alternative FDA-approved dosing of 400 mg initially and at week 2 and 4 followed by 200 mg every other week may be considered in patients ≤90 kg. This dosing regimen has a 2019 list price of $52 634 and net price of $26 877.

^bList and net prices were adjusted for inflation using the consumer price index. All prices are shown adjusted to the value of the USD in 2009. For reference, $1 in 2009 has the same buying power as $1.19 in 2019.

^cCalculated as the average change per year from later of 2009 or first year for which pricing data available through 2019.

^dThe average discount was calculated as (list price − net price) / list price.

SSR Health estimates net prices for branded drugs manufactured by publicly traded companies using company-reported sales and number of units sold each quarter across the United States. Net prices account for all manufacturer discounts, including rebates to payers, coupon cards, 340B discounts (discounted prices to organizations caring for low-income and vulnerable patients), and any other concession accounted for in the reporting of sales. The robustness of SSR Health data in estimating net prices for prescription drugs has been demonstrated in peer-reviewed research.³ Net pricing for tildrakizumab was not available as it is manufactured by a nonpublicly traded manufacturer.

For each drug and year, we calculated average list (wholesale acquisition) and net costs of psoriasis treatment for the initial year of therapy for an 80-kg patient based on US Food and Drug Administration–approved recommended dosing. We adjusted prices by inflation using the consumer price index. All prices are shown adjusted to the value of the US dollar in 2009.

Results

For all drugs studied, list prices increased substantially over time, with the greatest increase observed for tumor necrosis factor inhibitors, which increased by approximately 200% from 2009 to 2019 (annual mean change for etanercept, 12%; adalimumab, 12%; and certolizumab, 10%). Although net prices steadily increased until 2016, they began to decrease for ustekinumab in 2016, secukinumab and guselkumab in 2017, and brodalumab, adalimumab, and certolizumab in 2018 (Figure).

Figure. Changes in Annual Treatment Costs for Medications, Calculated Based on List Prices and Net Prices and the FDA-Approved Dosing Regimen for a Standard 80-kg Patient With Psoriasis.

Annual treatment costs were adjusted for inflation using the consumer price index and adjusted to the value of the USD in 2009. Net prices are net of all concessions made by manufacturers including rebates, coupon cards, 340B discounts, prompt pay discounts, return provisions, and any other deductions captured in the reporting of net sales. FDA indicates the US Food and Drug Administration; USD, United States dollar.

As of 2019, there was a large (30%-59%) and widening gap between list and net prices because of increasing discounts. The list price was highest for certolizumab ($94 379), followed by the interleukin (IL)-17A inhibitors secukinumab ($77 883) and ixekizumab ($75 848), and lowest for the oral phosphodiesterase-4 inhibitor apremilast ($34 545); net price was highest for the 3 tumor necrosis factor inhibitors (certolizumab, $48 193; etanercept, $43 910; and adalimumab, $39 751) and lowest for the IL-17–receptor inhibitor brodalumab ($17 692) (Table).

Discussion

We identified substantial price increases from 2009 to 2019 for self-administered psoriasis therapies. Even after accounting for inflation and discounts, the net price of some therapies more than doubled, highlighting the financial burden on payers and patients for these therapies.

Although insurers may benefit from lower net prices because of the ability to negotiate for discounts for formulary placement, patients’ out-of-pocket expenses are often based on list prices. High-deductible plans use list prices to calculate patients’ financial responsibility, making these therapies unobtainable for some patients. In addition, we observed that a decrease in net price for incumbent products coincided with the US Food and Drug Administration approval dates of novel therapies, including ixekizumab in 2016, brodalumab and guselkumab in 2017, and certolizumab for the indication of psoriasis in 2018.⁴ This suggests that competition from entry of new branded products may lead to discounts that primarily benefit payers rather than benefiting uninsured and underinsured patients who pay based on the list price. Interestingly, net prices for tumor necrosis factor inhibitors, which are used across multiple indications, did not decrease similarly. Limitations of this study include the use of aggregated data, which precludes estimating to what extent discounts are due to rebates to payers, discounts to patients (eg, such copay or drug cost assistance), or other concessions. Our work has implications for future research, as net price, along with drug safety and efficacy data, would be useful for more accurately evaluating the cost-effectiveness of psoriasis treatments.