Express Scripts will exclude 32 drugs from its 2020 national formulary, including 10 multisource branded drugs and 22 single-source brands. The company excluded 50 drugs in 2019.

The omitted multisource branded drugs have cheaper direct generic equivalents and are expected to save the employers who use Express Scripts’ formulary an additional $3.8 billion in 2020 (ESI press release, accessed Oct. 18, 2019). The single-source brands have generic therapeutic alternatives in the formulary.

The PBM is also moving 19 drugs in the formulary from preferred tier to nonpreferred tier. Both these changes are made to promote judicious use of medications and reduce costs.

Although Express Scripts not does shut out some new drugs in the specialty category, it is primarily focused on traditional drug classes.

New exclusions under specialty drug class:

Factor VIII Recombinant Products – For 2020, Express Scripts is excluding Nuwiq, which in 2019 enjoyed a favorable Tier 2 placement on the PBMs National Preferred Formulary, covering almost 72 percent of its lives (DRG fingertip formulary data, accessed Oct. 18, 2019).

Granulocyte Stimulating agents – Granix, a drug from Teva pharmaceuticals, with action similar to Neupogen, has been excluded for 2020. It was given advantageous placement on Tier 2 covering almost 80 percent of its lives in 2019. Nivestym and Zarxio, the biosimilars for Neupogen, have been given preferred status in the formulary.

Multiple Sclerosis (oral) – While Aubagio is in the excluded list, Gilenya, Mayzent, and Tecfidera are on the preferred list for 2020. In 2019, Aubagio was placed on Tier 3 of the PBMs formulary, covering almost 83 percent of its lives. Mayzent, Novartis’ breakthrough drug to treat secondary progressive MS with orally, was given a preferred status at Tier 2 within a month following its FDA approval.

New exclusions under nonspecialty drug class:

Insulins – ESI is completely knocking out Relion Novolin from its formulary. Relion Novolin, which consists of several types of Novolin such as Novolin N, Novolin R, and Novolin 70/30, were present on the PBMS’s national formulary in 2019. But they were offered to only 18 percent of the lives at Tier 2 under ESI with 70 percent of its members excluded from the coverage. Novo Nordisk is introducing authorized generics for its Novolog insulin, which could improve its coverage on the Express Scripts’ formulary in 2020.

Glucose meter strips – Express Scripts has newly excluded Bayer test strips for 2020, which joined the list of previously excluded strips from manufacturers like National Medical, Omnis Health, Roche, Trividia, Unistrip. New for 2020, ESI has preferred test strips from Freestyle, and Precision Xtra, which joined Onetouch (Lifescan). In 2019, ESI placed OneTouch test strips on Tier 2 covering almost 80 percent of its lives. Freestyle and Precision Xtra test strips were not covered for almost 75 percent of its lives but the placement will change following its preferred status in 2020.

Source: ESI

Express Scripts aggressively excluded drugs since 2014 to curb high costs and improve patient access to low cost drugs

Express Scripts was one of the trendsetters in using formulary exclusions as a method of saving costs for its clients. Since 2014, the PBM has followed an aggressive formulary exclusions approach, most notably the exclusive agreement with AbbVie for its hepatitis C drug, Viekira Pak, over Gilead’s Sovaldi. This generated significant savings for plan sponsors. These exclusions historically drove competition between brands, allowed generics to gain preferable status, and utilized newly available clinical information to improve care for its members. Currently, the PBM is using drug exclusions as one of the major approaches to attain lowest net cost.

With a solid exclusion list made, the PBM may reduce the number of new exclusions in the coming years. Also, with the Cigna-Express Scripts mega-merger, the PBM has ventured into using various utilization management tools to improve the cost and efficacy of drugs on its formulary. It will be interesting to watch if the PBM uses its exclusion strategy to tackle the emerging expensive treatments in 2021 or uses the various utilization techniques in collaboration with the medical management team of Cigna.

With its merger with Cigna, Express Scripts has new heft in negotiating with drug manufacturers. Cigna has begun introducing initiatives aimed at making prescription drugs more affordable. It will have a new offering in 2020 dubbed "Embarc Benefit Protection," which essentially turns Cigna into an in-network gene therapy provider. Plans pay a monthly fee for network access and consumers have no out-of-pocket payments for Luxturna (Spark Therapeutics) or Zolgensma (Novartis), the first two therapies included in the new offering. There is an opportunity for other specialty drug manufacturers to get into the program as Cigna is open to adding other therapies in the future.

Cigna is also partnering with Eli Lilly, Novo Nordisk and Sanofi, to offer a $25 copay cap for 30-day supplies of insulin at the point of sale. This new "Patient Assurance Program" is available to members participating in nongovernment funded pharmacy plans managed by Express Scripts.

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