A Novel Formulary Built for the Evolution of Drug Pricing

Nov 13, 2018

Our new National Preferred Flex Formulary provides employers and health plans a pathway to cover lower list price products, helps deliver lower member out-of-pocket costs, and reduces reliance on brand rebates.

Tags
  • Commercial
  • Hepatitis C
Better Access Better Value

As drug pricing strategies continue to evolve, Express Scripts is keeping clients ahead of the game. Today, we’re introducing a novel formulary to provide employers and health plans a better opportunity to leverage changing dynamics to help lower their members’ out-of-pocket costs.

The Express Scripts’ National Preferred Flex Formulary, available January 1, 2019, provides a way for plans to cover lower list price products, such as new authorized alternatives that drug makers are bringing to the market, and reduce reliance on rebated brand products.

What are authorized alternatives?

As we wrote about recently, immediate list price decreases for products already on the market can pose challenges for employers and health plans that already have underwritten plan offerings and benefit designs for upcoming years based on existing economics.

By introducing authorized alternative products, through a new or additional National Drug Code (NDC) with a lower list price, we can create a competitive dynamic more similar to a generic coming to market. Cash-paying patients can have immediate access to the lower-priced medication. Meanwhile, employers and health plans can choose which product to cover that is best for their plan and their members:  the lower-priced option or the original brand, which may have a rebate.

Over time, plans, pharmacies and others in the supply chain can transition to a new pricing model and the drug maker could ultimately retire their high list price product.

Some manufacturers have already followed our lead to create a pathway to help close the “gross-to-net bubble,” and give cash-paying patients immediate access to more affordable medicine in a way that will not destabilize the drug supply chain.

Our new National Preferred Flex Formulary demonstrates our flexibility to keep clients ahead of industry trends, so that they can fully leverage new opportunities to lower their prescription drug costs.

National Preferred Flex Formulary

The National Preferred Flex Formulary is a comprehensive formulary that will mirror our industry-leading National Preferred Formulary -- covering more than 3,800 brand and generic medications -- and will follow Express Scripts’ clinical-first formulary decision process for all new therapies that come to market.

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  • When a manufacturer launches a lower-cost authorized alternative to a branded medication currently on the market, Express Scripts will evaluate the product for placement on the National Preferred Flex Formulary.
  • If appropriate, the authorized alternative product will be added to the Flex formulary with preferred or possibly non-preferred status. The innovator brand-name product, and potentially other products in the therapy class, then will be excluded from coverage.
  • Members enrolled in the Flex formulary who have a high-deductible or co-insurance plan design can have immediate access to the lower-priced authorized alternative medication.

Branded innovator products will remain preferred or non-preferred on other formularies, including Express Scripts’ standard National Preferred Formulary, while the authorized alternative product may be excluded.

Asegua Therapeutics’ authorized alternatives for hepatitis C treatments Epclusa®(Sofosbuvir/Velpatasvir) and Harvoni® (Ledipasvir/Sofosbuvir) will be the first authorized alternatives managed through the National Preferred Flex Formulary. Additional products will be evaluated for inclusion on the new formulary as more drug makers bring authorized alternatives products to market.

Express Scripts is at the forefront of creating strategies that move our nation toward better, more affordable access to prescription drugs. The National Preferred Flex Formulary is just one more example of how we champion a more sustainable pricing model, where manufacturers are more easily able to do the right thing for patients, and where payers can choose the model that best helps them achieve their goals.

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