Inflammatory Conditions Care Value Program Makes America’s Costliest Medication Class More Affordable

Sep 8, 2016

New value-based model aligns drug payments to specific medical conditions and refunds payers for early discontinuation of expensive medications.

  • Inflammatory Conditions

Rochelle Article

Express Scripts Inflammatory Conditions Care Value Program℠ is a comprehensive approach to control costs and improve care for people with inflammatory conditions like rheumatoid arthritis, psoriasis and Crohn’s Disease.

Through the combination of indication-specific formulary management and refunds for early discontinuation of therapy, this new program is the nation’s most comprehensive approach to better align a drug’s price with the value that drug provides a patient.

Painful inflammatory conditions like rheumatoid arthritis can cripple patients and obliterate payer budgets. By finding creative ways to take better care of patients and protect our clients’ budgets, Express Scripts is uniquely tackling one of the biggest health challenges facing our country today.

Approximately 10 million Americans live with an inflammatory condition. The biologic medications used to treat these conditions were the country’s costliest therapy class in 2017, representing 15.3% of all U.S. pharmacy spending.

Superior, Specialized Care for Patients

The program provides patients access to comprehensive and clinically appropriate treatment options, while surrounding patients with specialized care from the Accredo specialty pharmacy’s Rheumatoid Arthritis and Inflammatory Disease Therapeutic Resource Center®, where patients’ average medication adherence rate is 8% higher than what similar patients achieve when filling the same medications from retail pharmacies.

Accredo supports patients from their initial prescription through highly specialized pharmacy and nursing care. It offers thorough gap-in-care intervention outreach, proactive therapy-effectiveness assessments, and extensive patient training and education, all of which drive better adherence and health outcomes.

Specialized care greatly matters for patients with inflammatory conditions. In the same way patients go to a rheumatologist for arthritis, they should work with expert pharmacists who uniquely understand the illness and how best to treat it. Our Therapeutic Resource Centers provide world-class care, ensuring everyone gets the most out of their treatment.

Early Discontinuation Refunds

An average prescription for a specialty medication to treat an inflammatory condition currently costs U.S. plan sponsors $4,042. Between 21% and 36% of patients discontinue these medications within the first 90 days. In these instances, the patients receive minimal health benefit for the medication but employers are still burdened with the high cost of those initial prescription fills.

As part of the Inflammatory Conditions Care Value Program, Express Scripts is providing a unique savings guarantee, refunding participating plan sponsors up to $6,000 if a patient discontinues any preferred anti-inflammatory medication within the first 90 days. While Express Scripts has previously offered refunds for early discontinuation of a single medication, this new reimbursement approach is the country’s first value-based refund to span multiple preferred medications that treat a group of diseases.

The high price for these medications has always been a budgetary challenge, but one of employers’ growing frustrations is paying for an expensive medication that doesn’t ultimately help a patient get healthier. By sharing risk and pursuing novel solutions, Express Scripts is minimizing our clients’ financial exposure if a patient needs to switch medications or discontinue treatment early.

More Precise, Indication-Based Drug Management

Inflammatory diseases comprise several very different types of conditions, from rheumatoid arthritis to dermatological conditions like psoriasis, to inflammatory bowel conditions like Crohn’s disease. Because the industry has historically constructed formularies to cover the entire range of inflammatory conditions, many of the medications that are narrowly indicated for one or two specific conditions have not been able to compete effectively with the two major nonspecific anti-inflammatory medications.

As part of the Inflammatory Conditions Care Value Program, Express Scripts will now manage a formulary category around each individual inflammatory condition. Niche, single-indication products will be able to compete head-to-head with the nonspecific products, and this more precise approach to formulary management will enable Express Scripts to leverage the additional competition to make this therapy class more affordable for participating plans. 

Express Scripts is a pioneer in indication-level management of drugs, which is a core component of our existing Oncology Care Value Program®, Rigorous clinical documentation ensures the appropriate therapy option is used and patients get the medication they need. As more treatment options become available, the opportunities increase to drive competition and drive down costs.

All patients stable on their current therapy will continue to have access to the medication they are currently taking.

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