PBM expands pay for value to RA drugs

May 5, 2016

Express Scripts will implement more programs that pay for drugs based on their effectiveness, according to the PBM’s chief medical officer Steve Miller, MD. Simultaneously, the PBM plans to implement a spending cap on diabetes medications.

Express Scripts will implement more programs that pay for drugs based on their effectiveness, according to the PBM’s chief medical officer Steve Miller, MD.

Miller

Simultaneously, the PBM plans to implement a spending cap on diabetes medications to “protect our clients from skyrocketing costs and budget uncertainty,” Miller said in a recent blog post. Its new drug pricing plans will be effective on or before January 1, 2017.

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In March, the PBM implemented its Oncology Care Value Program, which pays for cancer drugs based on how well studies show they work. “We are very pleased with the early results we have seen. The program has enrolled 15 million lives, is working as we had hoped, and the affected patients have been able to get on the best medication without an issue,” Miller said. He declined to name the cancer drugs that have been proven to be most effective.

Now, Express Scripts is expanding the pay for performance program to drugs for rheumatoid arthritis, Crohn’s disease, and dermatological conditions such as psoriasis and psoriatic arthritis.

Express Scripts will be the first PBM to manage a formulary to each of the four sub-indications within this family of conditions: 1) rheumatoid arthritis, 2) the dermatological conditions like psoriasis and psoriatic arthritis, 3) ankylosing spondylitis, and 4) the inflammatory bowel diseases like Crohn’s Disease and ulcerative colitis,” Express Scripts spokesperson David Whitrap told FormularyWatch.

“This additional layer of formulary precision breeds greater competition among manufacturers and lower costs for our clients,” Whitrap said. “By evaluating formulary placement separately within each of these 4 indications, we are able to create more head-to-head competition between clinically equivalent products, which helps us negotiate larger discounts for our clients.”

Under its new pricing model, medications indicated for only 1 or 2 of the 4 inflammatory diseases will be on equal playing field with those that have several indications, such as Humira and Enbrel. 

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Miller said Express Scripts’ diabetes spending cuts were necessary because “a lack of competition among insulin products has helped hold diabetes costs high.” As we have done with other SafeGuardRx programs, Express Scripts will take on this financial risk to protect our clients from skyrocketing costs and budget uncertainty,” Miller said.

In 2014, Express Scripts made Lantus (insulin glargine) the preferred long-acting insulin on its National Preferred Formulary, “in part because we knew it would be the first long-acting insulin to potentially face competition from a follow-on biologic,” Miller said.

“By having Lantus preferred for more than three years, the majority of Express Scripts diabetes patients are stabilized on Lantus. Therefore, if the follow-on biologic to Lantus receives FDA approval in December, 2016 as expected, Express Scripts’ clients are well positioned to leverage this new competition among clinically equivalent insulins to achieve price discounts that previously have been unavailable.”

In addition, the PBM’s new diabetes program will include a “unique quality-based network of preferred pharmacies that are committed to delivering high levels of care to patients with diabetes and have demonstrated a history of achieving specific quality metrics, such as improved adherence rates and A1C levels,” Miller said.

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