Supporting Patients through Formulary Changes

Oct 6, 2016

At Express Scripts, our focus is on driving value and the best clinical outcomes.

Jennifer Article

Formulary management is one of our most effective tools for reducing the amount payers and patients spend on prescription drugs. This process of categorizing individual medications as preferred, covered with higher patient cost-sharing, or excluded from coverage has two primary benefits:

  • Providing leverage that Express Scripts (or other pharmacy benefit managers) uses to negotiate for lower prices from pharmaceutical manufacturers;
  • Eliminating wasteful spending on “me too” drugs that have higher costs, but no additional clinical benefit than others in the market.

Our goal is providing doctors and their patients with the broadest possible access to safe and affordable medications. And that means helping payers control spending so the pharmacy benefit remains sustainable. Our National Preferred Formulary, the nation’s largest with 25 million covered individuals, is expected to save participating plan sponsors a total of nearly $5 billion between 2014 and 2017.

Achieving that goal requires a thoughtful process and a surgical approach. Unlike some plans, we don’t exclude every drug that promises even a modest price savings – rather, our focus is on driving value and the best clinical outcomes. In 2017, our National Preferred Formulary will exclude 85 drugs while ensuring access to more than 3,800 others.

We Support Patients

No one likes surprises, especially when it comes to health care.

We know it’s important to reach people, and their physicians, with news of a formulary change well before they reach the pharmacy counter or go online to order a refill. And it’s not enough to simply tell them a medication won’t be covered after January 1 – we have to offer safe and effective alternatives.

Next year, slightly more than one-tenth of a percent of individuals covered under the National Preferred Formulary will be impacted by a prescription-drug exclusion. We are taking a multi-layered approach to guide them through the change:

  • This fall, patients will receive individualized letters and emails letting them know which of their medications will no longer be covered, and listing clinically equivalent alternatives to discuss with their physicians
  • Prescribers and pharmacists also receive notifications of overall formulary exclusions and alternatives so they’re prepared to take action
  • In December, patients receive reminder letters and emails
  • In early January, our specialized pharmacy clinicians call and offer assistance for the few impacted patients who are taking multiple excluded medications, or particularly complex drug regimens
  • Physicians who use electronic medical records and ePrescribing can see at the site of care which medications are covered and most affordable
  • Any patient who still attempts to fill an excluded medication immediately receives a letter and email reminder of the change and recommended alternatives

Throughout the process, we also offer resources and counseling from specialized pharmacists online and over the phone.

Health and Care Come First

Our dedication to improving health care permeates the formulary management process.

Even in cases where an exclusion is possible because alternative medication exists, we weigh any potential cost savings against the clinical impact it could have on the people we serve. We don’t drop a medication simply because we can.

Sometimes we apply a formulary change only to patients who are new to therapy, rather than requiring people to switch when they are established on a medication for a sensitive medical condition. If a drug is given for a specific time period, rather than long-term chronic use, we don’t interrupt that treatment. We avoid any situation where switching could lead to a disruption in therapy, an adverse outcome, or a deterioration of their medical condition.

At Express Scripts, our ultimate goal is to combat the rising cost of health care and keep medications within reach of the millions of people we are privileged to serve.

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Lab Staff
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