Express Scripts, a pharmacy benefit manager (PBM) that administers prescription drug programs for more than 100 million Americans, has announced the exclusion of more than a dozen popular OINDPs from its 2014 national preferred drug list. The exclusion means that many of the patients whose benefits are administered by Express Scripts would have to pay full retail price like Advair or Omnaris, often hundreds of dollars per inhaler or spray.
In excluding products for the first time in 2014, Express Scripts is following an industry trend; PBM CVS Caremark Pharmacy Services has been excluding a number of expensive drugs, including some OINDPs, for several years, and its 2014 Formulary Drug Removals list includes 13 OINDPs.
According to Express Scripts spokesperson David Whitrap, approximately 30 million members are covered by payers who will adopt the national preferred formulary, and the company expects that only a small percentage of those members will be affected by the exclusion of 48 products, of which approximately 25% are OINDPs.
The Express Scripts list of excluded drugs includes seven inhaler brands:
- Advair Diskus/HFA (GSK)
- Alvesco (Sunovion)
- Breo Ellipta (GSK)
- Flovent Diskus/HFA (GSK)
- Maxair Autohaler (discontinued as of Dec. 31, 2013)
- Proventil HFA (Merck)
- Xopenex HFA (Sunovion)
and five nasal sprays:
- Beconase AQ (GSK)
- Omnaris (Sunovion)
- Rhinocort Aqua (AstraZeneca)
- Veramyst (GSK)
- Zetonna (Sunovion).
The company emphasizes that its independent Pharmacy & Therapeutics (P&T) committee ensures that the formulary includes effective products available to members in all classes of therapy; however, “If there are more expensive products that, according to our independent P&T committee, offer no additional health benefit than products already covered on the formulary, we may place them on a higher tier of the formulary –meaning that they would require a larger copay– or remove these products altogether,” Whitrap said.
“Drug choices in some classes are larger than ever,” Whitrap points out, “with many products costing more with no additional health benefit.” Express Scripts sorts inhalers for respiratory conditions into only three classes: “Pulmonary Anti-Inflammatory/Beta Agonist Combination Inhalers,” “Pulmonary Anti-Inflammatory Inhalers,” and “Beta-2 Adrenergics.” All of the nasal sprays for the treatment of rhinitis are lumped together as “nasal steroids.”
Pharmaceutical companies and PBMs may disagree over what constitutes an additional health benefit. For example, GSK has touted Breo Ellipta, which has just launched in the US, as the first once-daily ICS/LABA inhaler for COPD, Express Scripts, however, places Breo Ellipta into the same category as Dulera and Symbicort, both of which are twice-daily medications and both of which are included in the formulary.
Express Scripts did not comment specifically on the prevalence of OINDPs among the excluded drugs, however, Whitrap noted that another factor driving the exclusion of high cost drugs from formularies has been “pharmaceutical manufacturers’ tactics that incentivize patients to choose higher cost drugs when lower cost, clinically equivalent alternatives are available.” Almost all of the drugs Express Scripts has excluded offer patients coupons that cover the cost of copayments, making the drug free or nearly free for the patient while payers cover the higher cost.
Sunovion, for example, offers a “Relief is here co-pay program” for Zetonna, suggesting that patients “Create your Relief Is Here Co-pay Program card in just 3 easy steps to get ZETONNA® (ciclesonide) Nasal Aerosol for only $17* on every prescription fill,” and the same deal is available for Omnaris. GSK offers free trial prescriptions and coupons for both Advair and Breo Ellipta.
