3 Solutions Healthcare Payers Need Now

Apr 28, 2016

With our clients, we move forward together to practice pharmacy smarter and drive continued success.

New Pill Bottle

Over the past 18 months, our SafeGuardRxSM solutions have helped healthcare payers address key threats to affordable pharmacy care. For each of these innovations, we took a comprehensive approach to a specific class of drugs or industry challenge, we identified novel ways of partnering with drug manufacturers, and we ultimately delivered to our clients superior levels of care, lower drug costs, and protection from future financial uncertainty.

The Tradition of Previewing a Smarter Approach to Pharmacy

Our annual Outcomes Symposium, where we meet with hundreds of our clients to discuss the future of pharmacy, has served as the perfect forum to preview these programs.

In the spring of 2013, I stood before our clients and discussed how they would be able to lower costs while maintaining the same level of care for their members through a clinically-driven closed formulary. Three months later, we announced our first drug exclusions within our National Preferred Formulary, a strategy that has since saved participating clients $3 billion.

In the spring of 2014, as the country faced the unsustainably high cost of the new hepatitis C product Sovaldi® (sofosbuvir), I asked clients to join a coalition for fair drug pricing that would support Express Scripts moving our market share to a lower-cost competitor when one arrived to market. Eight months later, we announced our Hepatitis Cure Value ProgramSM, saving our clients more than $1 billion annually while expanding patient access to curative therapy.

Last spring, I discussed the need for the country to rethink how to pay for cancer treatment. Six months later, we announced our Oncology Care Value Program®, a program that leverages our indication-based capabilities to better align the cost of the drug to the value it provides.

Taking on Payers’ Biggest Pain Points

This week, I am previewing for our clients forthcoming SafeGuardRx solutions that target three of the most significant challenges for payers:

  • Diabetes – the costliest traditional therapy class;
  • Inflammatory Conditions – the costliest specialty therapy class; and
  • Unique market events – unexpected price increases on products that should not be expensive.

While we continue to hone these new solutions before implementing them next year, we are able this week to provide a peek into some of their key components.

Diabetes Care Value ProgramSM

A lack of competition among insulin products has helped hold diabetes costs high. In 2014, Express Scripts made Lantus® (insulin glargine) the preferred long-acting insulin on our National Preferred Formulary, in part because we knew it would be the first long-acting insulin to potentially face competition from a follow-on biologic.

Patients with diabetes need stability with their therapy. Changing insulins when a more affordable option comes to market is not possible for many patients. By having Lantus preferred for more than three years, the majority of Express Scripts diabetes patients are stabilized on Lantus. Therefore, if the follow-on biologic to Lantus receives FDA approval in December 2016 as expected, Express Scripts’ clients are well positioned to leverage this new competition among clinically equivalent insulins to achieve price discounts that previously have been unavailable.

We want to deliver TRC-level care to everyone, and that means working with retail pharmacy partners that have the same commitment to patient outcomes. This new program will include a unique quality-based network of preferred pharmacies that are committed to delivering high levels of care to patients with diabetes and have demonstrated a history of achieving specific quality metrics, such as improved adherence rates and A1C levels.

To demonstrate our commitment to the success of this program, we will implement a spending cap on diabetes medications for participating plans. As we have done with other SafeGuardRx programs, Express Scripts will take on this financial risk to protect our clients from skyrocketing costs and budget uncertainty.

Inflammatory Conditions Care Value ProgramSM

Similar to Oncology Care Value Program, our Inflammatory Conditions Care Value ProgramSM will use an indication-based approach to formulary management. We will be the first PBM to divide inflammatory diseases into four separate indications, allowing products with only 1-2 indications to be on an equal playing field with products that are indicated across all of various inflammatory diseases. This more precise approach to formulary management allows us to achieve more head-to-head price competition among clinically equivalent medications, which will help control costs for our plans and ensure that patients have access to the best medication to treat their specific inflammatory condition.

Market Events Protection ProgramSM

Increasingly over the past two years, the pharmaceutical industry has experienced dramatic price increases and new generic launches that seem to transform affordable medications to unaffordable overnight. From compound pharmacies exploiting a loophole to sell products that have no clinical value, to manufacturers rolling out dramatic price increases for simple medications that have been on the market for decades, these sometimes unforeseen market dynamics require payers to react rapidly or be faced with significant amounts of wasteful drug spending.

And while we have always led the industry with the earliest and most aggressive actions to counter these extraordinary market situations in the supply chain, we now have an opportunity to accelerate these solutions even further.

Our Market Events Protection ProgramSM will tackle targeted opportunities and drive members to the most clinically appropriate, cost-effective therapy or dispensing channel. We can protect payers from hyperinflating generics, address massive average wholesale price (AWP) increases on brands, and reduce the impact of captive pharmacy arrangements that drive up spend.

Through our data solutions, we are now able to identify many of these events as they are just beginning to surface. And through our new Market Events Protection Program, we will be able to expedite the process it takes to identify an issue and bring a solution to market. In moments like these, speed is everything.

Moving Forward Together

Our Outcomes Symposium is a time where we collaborate with clients and explore the future of their pharmacy benefit. That’s why it’s appropriate to preview these programs with our clients this week to gain their support and incorporate their feedback into the final product.

With our clients, we move forward together to practice pharmacy smarter and drive continued success.

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