Largest PBM Enhances Formulary Control with “Not Covered” List

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Express Scripts Inc., the world's largest PBM for employers and health plans, recently released a list of 44 drugs that they will now exclude from coverage beginning January 1, 2014.
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The company cites increasing payer costs resulting from rising drug prices and manufacturer copayment assistance programs as the impetus for the formulary exclusions. Employers and health plans are expected to adopt the not-covered list for their 2014 formularies, jeopardizing access to these drugs for a significant portion of the commercial market.

The payer industry has been moving toward more aggressive formulary management for some time, and manufacturers should expect this trend to continue. In 2012, the second largest PBM, CVS Caremark, instituted an excluded drug list for its health plans. Based on a comparison, there is limited overlap in the therapy classes targeted for drug exclusion from both PBMs’ formularies. Drug classes targeted by both PBMs include: Moreover, given other payers’ restrictions around manufacturer copayment assistance programs (e.g., United Health’s ban of copay coupons for certain drugs within their preferred network), as well as the impending decision of whether copay assistance programs will be allowed in the health insurance exchange population, manufacturers face a greater imperative than ever to create alternative methods to provide financial assistance to patients outside of the traditional copay assistance programs and coupons.

    Erectile Dysfunction
    Nasal steroids
    Short-acting beta-agonists
    High blood pressure: angiotensin II receptor antagonists (in combination with diuretics)
    Growth hormones
    Testosterone replacement: androgens
    Diabetes: DPP-4 inhibitors
    Opthalamic prostaglandins
    Diabetes: insulins

See the recently released Express Scripts 2014 formulary.

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