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| DATE | 2017-06-11 |
| FROM | Ruben Safir
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| SUBJECT | Re: [Hangout - NYLXS] Time to end the kickbacks and the control
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https://aishealthdata.com/news/health-plans-pbms-embrace-drug-exclusions-new-formulary-offerings
Health Plans, PBMs Embrace Drug Exclusions With New Formulary Offerings
Aggressive formulary management will continue to play a key role in
containing pharmaceutical costs, especially those related to specialty
products, in 2015. No better example exists than the rise of formulary
exclusions, or the concept of blocking from coverage select brand-name
drugs rather than relegating them to higher cost tiers, in order to
achieve better manufacturer discounts.
CVS Caremark Corp. and Express Scripts Holding Co. have both grown their
exclusion lists for 2015, while Catamaran Corp. in mid-2014 launched its
optional Value Formulary that does not exclude any specialty drugs. And
despite public debate about member disruption and the potential impact
of exclusions on pharmacy trend and greater medical spend, more payers
and PBMs are going ahead with exclusionary strategies for 2015.
“At this point, most of my clients are grudgingly accepting the ‘new
world order’ of exclusion-based formularies,” Josh Golden, practice
leader, employer consulting, at Pharmaceutical Strategies Group LLC,
tells AIS. “And while specialty drug classes used to be off limits for
aggressive formulary management, that old rule really no longer applies
for a number of specialty disease states.”
Craig Oberg, R.Ph., managing consultant at The Burchfield Group,
estimates that about two-thirds of clients have adopted formulary
exclusions for 2015. “The savings generated through exclusions is less
about reductions in ingredient cost and more about preserving
manufacturer rebates,” he observes.” The number of opportunities to
exclude products has and will continue to decline with each successive
year. The use of exclusions as a cost management [tool] for traditional
medications will lose importance in the future. The opportunities for
exclusions in the area of specialty medications will be limited due to
the necessity of having a minimum of two products that can deliver
nearly identical clinical results.”
“There’s no doubt that the PBMs’ specialty formulary maneuvers are
driving significant manufacturer incentives behind the scenes,” adds
Golden. “The crucial question is whether those incentives flow back to
the plan sponsor, or get pocketed by the PBM. And the answer to that
question depends on the client’s contract terms.”
Here are a few of the exclusionary options new to the marketplace for 2015:
Prime Therapeutics LLC, which has not “advocated heavily” for
formulary exclusions in the past, in late 2014 introduced three options
for its Blue Cross and Blue Shield plan owners and clients as well as
self-insured employer groups. The first is a basic option that
identifies four categories for utilization management without
grandfathering and offers the lowest amount of cost reduction at 75
cents per prescription; the other two are “true exclusion options” and
can result in net savings to the plan of up to $1.15 per prescription
(generics-focused option) or up to $2.80 per prescription (enhanced).
Independent Health in 2014 moved from an open to a closed three-tier
formulary design and will increase the number of drugs that are
non-formulary, including multi-source brand drugs, for 2015. Martin
Burruano, R.Ph., vice president for pharmacy at the Western New York
insurer, which operates its own PBM, explains this change was partly in
response to “manufacturer coupons…negating the positive effects of a
tiered formulary design.” Moreover, the insurer has moved high-cost
generics into higher tiers across multiple therapeutic categories. “For
the drugs that are excluded, formulary alternatives are available,” he
adds. The savings associated with these changes are expected to result
in an approximate 3% decrease in overall drug spend.
Envision Pharmaceutical Services (EnvisionRxOptions) in late 2014
unveiled the Performance Formulary, in which clients must “opt in” to
use the drug list that “integrates formulary exclusion logic with step
therapy.” The formulary features 10 step therapies and 11 exclusions;
categories subject to exclusion are acne, diabetes testing supplies,
insulins, injectable diabetes medications, overactive bladder
medications and androgens. Envision estimates that clients can achieve
an additional 5% to 10% in savings, while expected member disruption is
typically less than 1.5% of utilizing members.
In addition to existing formulary options that exclude drugs used
for cosmetic purposes, weight loss, erectile dysfunction, and smoking
cessation, Navitus Health Solutions, LLC’s new SelectPlus Formulary
further excludes approximately 45 agents in categories and classes
deemed therapeutically interchangeable by the Navitus Pharmacy and
Therapeutics Committee. These include topical testosterone, nasal
steroids, long-acting opioids, diabetic test strips and insulin; some
specialty agents are also subject to exclusions. Navitus anticipates
savings anywhere from 6% to 10% with the new formulary product, which is
offered on an opt-in basis.
Contact Burruano via Frank Sava at frank.sava-at-independenthealth.com,
EnvisionRx spokesperson Josh Paulen at jpaulen-at-rxoptions.net, Golden at
jgolden-at-psgconsults.com, Navitus spokesperson Chantel Soumis at
chantel.soumis-at-navitus.com, Oberg via Christine Hanson-Ehlinger at
chanson-ehlinger-at-burchfieldgroup.com and Prime spokesperson Laura Aumann
at laumann-at-primetherapeutics.com.
Excerpted from the 1/9/2015 issue of AIS’s Drug Benefit News
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