As expected, the two PBMs’ lists keep getting longer, although there are relatively few overlaps. The lists offer some surprises, including Express Scripts’ decision to drop Amgen’s anemia products and both companies’ handling of the testosterone category.
Read on for our exclusive Guardians of the Galaxy commentary and links to the complete exclusion lists.
GUARDIANS OF THE FORMULARY
Over the past few years, formulary restrictions emerged to block access to specific products. The restrictions affect a PBM’s national formulary. Here are the 2015 lists:
AWESOME OBSERVATIONS, VOL. 1
A few insights, inspired by the Guardians of the Galaxy: Awesome Mix Vol.1:
- Ain’t No Mountain High Enough. The lists keep growing. Express Scripts has 66 products on its 2015 formulary exclusion list, compared with 48 in 2014. CVS Caremark’s 2015 list has 95 products, including 72 carryovers from the 2014 edition. Nostalgic readers will recall that CVS Caremark removed a mere 34 drugs from its 2012 standard national formulary. I guess there ain't no valley low enough, either.
- Escape (The Piña Colada Song). Drugs that are targeted for formulary exclusion usually fall into one or more of these categories: (1) Non-preferred, tier 3 drugs with very low utilization, (2) heavily promoted drugs in therapeutic classes with multiple generic alternatives, and/or (3) brand-name products with generic equivalents. Here’s what Express Scripts told me: “We only exclude products from our formulary that represent a significant amount of wasteful drug spend, and only when clinically appropriate alternatives exist.” So if you like getting caught in the rain...
- Ch-Ch-Ch-Cherry Bomb. This year, CVS Caremark increased its focus on “new to market” products, which it defines as “line extensions, new strengths, or new molecular entities.” New products that are “clinically significant” (the company’s words) will get an expedited formulary review. Express Scripts puts more emphasis on specialty drugs, such as the exclusion of Amgen’s Aranesp and Epogen.
- Come and Get Your Love. Plan sponsors that adopt the more restricted formulary will gain higher rebates and/or lower plan costs. For example, Express Scripts estimates that its 2015 exclusions affect less than than 0.2% of its members, but will come and get more than $1 billion for its clients and patients in 2015.
- Hooked on a Feeling. While nearly all exclusions are brand-name drugs, both PBMs have targeted brand and generic products in the newly complicated testosterone category. You know, it's the authorized generics and ooga-chaka, ooga ooga ooga chaka stuff.
We are groot. ‘Nuff said.
P.S. Yes, go see GotG. Right away.
P.S.2 In anticipation of the 2014-15 edition (due in late September), our 2013-14 Economic Report on Pharmaceutical Wholesalers and Specialty Distributors is on sale until the end of August.