Express Scripts Announces New Recommendations Tackling High Drug Prices
"High drug prices are one reason that the U.S. spends more per capita on healthcare than any other developed nation. For far too long, drugmakers have been charging whatever the market will bear for their medications, including drugs that do not provide any additional clinical value for patients," said
"Countering drugmakers' high prices includes seizing opportunities for generic and biosimilar drugs, forcing head-to-head competition between brand-drug makers and understanding new or updated
Lowest Net Cost
In 2019, our National Preferred Formulary (NPF), which covers more than 25 million Americans, will provide access to 3,886 medications. Among the changes that take effect
These new exclusions contain:
- 22 drugs that have low-cost generic alternatives. Even when brand drugs include rebates, the generic drugs are better value.
- 12 instances of brand-to-brand competition where the drugs have the same active ingredient, but the excluded drug has a higher net cost.
- 11 specialty drugs that have a lower-cost brand or biosimilar alternative with a lower list price.
- 10 drugs that are multisource brands with direct generic equivalents.
- 9 short-term therapies, such as topical creams and ophthalmic treatments.
After clinical considerations, formulary preference is given to high-value therapies with the lowest net cost for clients, achieved through low list price, rebate or both. For example, in the HIV class, the 2019 NPF will prefer SYMFI™ and SYMFI LO™ (efavirenz, lamivudine and tenofovir disoproxil fumarate) with 40 percent lower list prices than ATRIPLA® (efavirenz/emtricitabine/tenofovir disoproxil fumarate), which will be excluded. For the treatment of hepatitis C, the 2019 NPF will prefer low-price leader ZEPATIER® (elbasvir and grazoprevir) and market leaders HARVONI® (ledipasvir/sofosbuvir), EPCLUSA®(sofosbuvir/velpatasvir) and VOSEVI® (sofosbuvir/velpatasvir/ voxilaprevir) in place of MAVYRET™ (glecaprevir/pibrentasvir).
In addition to formulary exclusions that help drive out waste,
Quality and Clinical Assurance for Patients
Our formulary development process requires a focus on clinical efficacy first. Financial considerations come into play only among clinically comparable products. This strategy ensures the drugs on our formulary meet members' clinical needs and improve health outcomes.
Approximately 0.2 percent of members enrolled in an NPF plan will see a change in 2019, and in those cases, we will use personalized treatments to help them access a treatment that works best. All affected members have access to formulary alternatives, including preferred brands and generics. For certain complex conditions where therapy stability is important, members who currently use an excluded medication, such as Atripla or Mavyret, will be automatically allowed continued coverage.
In the rare instance a member cannot use a preferred medication, we have a formulary exception process. A recent analysis of our NPF shows, on average, about 12 percent of members affected by annual formulary exclusions seek such an exception each year. Since annual formulary exclusions only impact approximately 0.2 percent of a plan's total lives, the number of members seeking a formulary exception is low. For example, in a plan with 100,000 members, approximately 24 members will seek a formulary exception. Of those, about two-thirds typically are approved to remain on the excluded product; however, the approval percentage varies by drug.
"Affordability, care and choice are critical priorities for plan sponsors and their members," said Dr. Miller. "Our NPF is a carefully crafted formulary that delivers savings with minimal member impact, leading to more favorable medication adherence and reduced wasteful spending. "
Click here for a list of 2019 National Preferred Formulary changes.
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