2019 National Preferred Formulary: Better Access. Better Value.
Despite promises to limit price increases, drugmakers are trying to game the market by delaying generic competition, blocking access to safe and effective biosimilars, and coyly deferring - not cancelling - list-price increases. This is why our work to expand access and maximize value is more important now than ever.
In our 2019 National Preferred Formulary (NPF), we have identified opportunities to address these issues – and others – as we champion broad, affordable access to innovative treatments. Payers save money and patients achieve better outcomes because of our work. In short, our NPF is the greatest example of how we make the market work for payers and patients by leveraging competition and directing members to medications with the lowest net cost.
Since 2014, plan sponsors representing more than 25 million Americans have relied on our industry-leading NPF to provide cost-effective access to critical therapies and reduce waste from high-cost medications that do not provide greater clinical value. Plans that implement our NPF trust the clinical expertise and guidance of our independent Pharmacy & Therapeutics (P&T) Committee, our ability to incent drugmakers to provide competitive pricing and, most importantly, our unwavering commitment to patient care.
The result is a highly effective, clinically based formulary that ensures everyone has a pathway to the medicine that will best treat their condition.
For the 2019 plan year, the NPF will provide plans, and their members, access to 3,886 medications while saving $3.2 billion. That means those members will get the medicine they need at the lowest cost.
Cumulatively, plans that have implemented NPF since its introduction will save $10.6 billion. Savings are important to sustaining and improving access to healthcare. Employers, health plans, government programs, unions and others want to provide benefits to their members and their families. When we can help payers save money on their pharmacy benefit, it allows opportunities for payers to invest in other important benefits for their members.
Countering drugmakers’ high prices includes seizing opportunities for generic and biosimilar drugs, forcing head-to-head competition between brand-drug makers, and understanding new and updated FDA indications and studies. When clinical considerations align with these opportunities, patients and payers benefit. Common scenarios include:
- Patent expiration: A new generic or biosimilar opens the door for decreased costs for that specific medication as we can potentially exclude the brand from preferred status on the formulary.
- New brand competition: Brands entering the market create additional competition, enabling Express Scripts to negotiate better pricing for all medications in the therapy class and potentially excluding high-cost brands.
- Changes in FDA-approved indications or new clinical studies: Updates to clinical literature can trigger an event where a drug that had a clinical advantage over others no longer has a clinical advantage, enabling Express Scripts to negotiate better pricing for medications in the therapy class and potentially excluding high-cost brands.
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.
2019 NPF Changes: All About Lowest Net Cost
Among the changes to the NPF that will begin on Jan. 1, 2019, are 48 new 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 a topical creams and ophthalmic treatments.
After clinical considerations, formulary preference is given to high-value therapies with the lowest net cost, 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), which has a list price that is 40 percent less 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% of all pharmaceutical purchase discounts, price reductions and rebates back to our core PBM commercial and health plan clients and their members. This has helped our clients achieve a record low drug trend of 1.1% for the first half of 2018.
Quality and Clinical Assurance for Patients
Our formulary development process calls for a focus on clinical review first. Financial considerations come into play only among clinically comparable products. This strategy ensures we are meeting members’ clinical needs and improving health outcomes.
Approximately 0.2 percent of members enrolled in an NPF plan will see a change in 2019, and we will use personalized communications 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 provided with 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% of members affected by annual formulary exclusions seek an exception each year. Since annual formulary exclusions impact an average of only 0.2% of a plan’s members, 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 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. Our NPF is a carefully crafted formulary that delivers savings with minimal member impact, leading to more favorable medication adherence and reduced wasteful spending.