2020 National Preferred Formulary: Improving Care and Value

Aug 22, 2019

Plan sponsors depend on us to deliver the most clinically appropriate prescription drug coverage – at the best value.

New Pills

Express Scripts is finding new ways to help our clients manage costs while giving members access to clinically effective – and cost-effective -- generic and brand-name drugs. We continue to create opportunities within our National Preferred Formulary (NPF) that will further improve affordability and access for payers and patients.

Collectively, between 2014 and 2020, Express Scripts expects to save participating NPF clients and patients $14.5 billion because of formulary exclusions. We make sure that we save money, but we also make sure that people get the medicine they need.

The NPF is designed to preserve member choice, and it continues to cover more than 92% of all available products. Because of our formulary strategies, employers who use the NPF are expected to save an additional $3.8 billion in 2020.

Our unique approach to formulary management is guided by an independent panel of clinical experts and a focus on clinical factors first. We then evaluate financial considerations among clinically comparable or optional products. The result is a clinically sound, cost-effective formulary.

2020 NPF Changes: Driving to the Lowest Net Cost

Among the changes to the NPF that will begin on Jan. 1, 2020, are 32 new exclusions that will help payers better manage medication spending while preserving patient access to effective therapies.

The vast majority of patients we serve – 99.63% -- will not see any changes to their coverage.

Some patients will be asked to use a different medication that achieves the same health outcomes at a lower cost. However, if any patient has a clinical need requiring a medication that is not on our formulary, we have provided a clear pathway to have that drug covered. Our goal is always to make sure a patient gets the medicine that helps them achieve the best outcome.

These new exclusions contain:

  • 10 drugs that are multisource brands with direct generic equivalents
  • 22 single source brands with therapeutic alternatives available on the formulary or as generics

After clinical considerations, formulary preference is given to therapies with the lowest net cost.

In addition to the exclusions, 19 products will move from preferred to non-preferred medications. A reminder: non-preferred medications will carry a higher cost share than preferred medications. Excluded products will not be covered.

Expanding Opportunities

Innovative formulary management includes seizing opportunities for generic and biosimilar drugs, forcing 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 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.

Driving Value for Clients and Patients

By providing pharmaceutical care to millions of people, we have the ability to drive more value for clients and patients, especially in the most expensive therapy classes, and we continuously uncover new avenues to control costs in a way that other pharmacy benefits managers cannot.

The list of new exclusions and preferred alternatives is available here.

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