- 2019 National Preferred Formulary includes low list price medications in high-cost categories
- Fewer than 0.2 percent of members will see a change in coverage for a medication
- Changes in 2019 will save plans an estimated $3.2 billion; cumulative savings for plans leveraging NPF since 2014 will be $10.6 billion
ST. LOUIS, Aug. 7, 2018 /PRNewswire/ -- Despite drugmaker promises to limit price increases, their ongoing efforts to game the system by delaying generic competition, blocking safe and effective biosimilars and refusing to eliminate list price increases are the main reasons medication remains unaffordable for many people. Today, Express Scripts (NASDAQ:ESRX) is taking action to address these tactics by exposing opportunities within our National Preferred Formulary that will further improve affordability and access for payers and patients.
"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 Steve Miller, M.D., chief medical officer, Express Scripts. "Formularies such as our National Preferred Formulary, which drives out waste and gives preference to medications with lower prices and high value, can help Americans save significantly on their healthcare costs without sacrificing quality or care."
"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 FDA indications and studies," said Everett Neville, R.Ph., executive vice president, strategy, supply chain and specialty. "Unfortunately, FDA approval is not assured when drugmakers abuse the drug approval system and enter into settlements or otherwise delay the launch of lower-cost competitors, including specialty drugs that treat inflammatory conditions. We remain committed to re-evaluating these therapy classes as soon as competitive products come to market."
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 Jan. 1 are 48 new formulary exclusions that will help payers better manage medication spending while preserving patient access to effective therapies.
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, Express Scripts is delivering value by passing approximately 95 percent of all pharmaceutical purchase discounts, price reductions and rebates back to our PBM commercial and health plan clients and their members. This has helped our clients achieve a record low drug trend of 1.1 percent for the first half of 2018.
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.
About Express Scripts
Express Scripts is a healthcare opportunity company. Empowered by our legacy as an industry innovator, we dare to imagine – and deliver – a better healthcare system with improved health outcomes and lower costs. From pharmacy and medical benefits management, to specialty pharmacy care, and everything in between – we uncover opportunities to make healthcare work better.
Our home base is St. Louis, but our reach extends across the nation, helping millions of Americans. We stand alongside those we serve, collaborating with our clients and partners to develop personalized solutions that make a meaningful difference.
We believe healthcare can do more. We are Champions For BetterSM.
For more information, visit Lab.Express-Scripts.com or follow @ExpressScripts on Twitter.
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