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What the Latest Express Scripts Value Program Means to Key Stakeholders

Jessica Cherian, PharmD
MediMedia Managed Markets

According to the Express Scripts 2015 Drug Trend Report, inflammatory conditions made up the top specialty therapy class when ranked by per-member, per-year spend, with an average cost per prescription of $3,035.96. The category saw a 17% increase in unit costs for the top two products by utilization, Enbrel and Humira Pen.

In an effort to combat the increasing spend on this class of high-cost diseases, the country’s largest PBM by volume of prescriptions has launched a value-based model that will combine indication-specific formulary management and refunds for early discontinuation of therapy.

The formulary management technique will create categories for each inflammatory condition with its own preferred and non-preferred medications to foster competition between single-indication and nonspecific products.

Express Scripts’ foray into value-based payment also includes a program that will provide plan sponsors with refunds up to $6,000 if a patient stops taking an anti-inflammatory medication on the company’s preferred list during the first three months of the prescription.

Between about a quarter and a third of patients with inflammatory conditions like rheumatoid arthritis and Crohn’s disease stop taking their medications within the first three months, according to Express Scripts. And, as the company noted in its press release, when that happens, the employers are “still burdened with the high cost of those initial prescription fills” even if the patient has stopped taking the medication and hasn’t benefited much from it.

Some commentators have noted that Express Script’s plans, which may sound good, will benefit Accredo, its specialty pharmacy business because patients in the program will be required to use Accredo instead of a competing pharmacy.

Still, Express Scripts may be writing the new script for controlling runaway drug costs. All payers are looking for ways to combat spending trends and drug price hikes. It is only a matter of time until similar models begin to emerge.

For manufacturers, these new models will mean that they can no longer compete simply on price to get their products on preferred lists. They will also have to prove value to differentiate their products by showing, for example, that they will lead to overall savings by avoiding costly events such as hospitalizations.

The news may not be all good for patients and providers. They may face additional hurdles and layers of approvals to obtain what they believe are the most appropriate treatments, even if Express Scripts says the goal here is to rein drug costs and keep treatment affordable. Consider patients with rheumatoid arthritis. Often they switch to other medications within a class after the effectiveness of a medication has worn off or perhaps it was never that effective to begin with. A program like Express Scripts may make that harder—and more expensive—to do.

My hope is that Express Scripts and any others who follow suit will find a way to minimize these drawbacks so these efforts to rein in drug costs don’t come at the expense of quality health care. 

Jessica Cherian, PharmD, is a Senior Clinical Services Manager at MediMedia Managed Markets and a part-time community pharmacist.