Express Scripts — one of the nation’s leading pharmacy benefits managers (PBMs) for both private employers and government health plans — has announced new lower prices on some 3,800 drugs coming at the start of the new year.
New lower formulary prices from Express Scripts
According to this press release, Express Scripts will introduce its National Preferred Flex Formulary (NPFF) beginning January 1, 2019.
The proprietary formulary is being introduced in an effort to reduce the reliance of big plans on branded drugs.
The NPFF aims to leverage a new breed of authorized alternatives from drugmakers in order to help move as many people as possible to cheaper generic options.
So far only two authorized alternatives called Epclusa and Harvoni — both used to treat hepatitis C — have been announced as being available through the NPFF.
Reuters reports that the Gilead Sciences Inc, the manufacturer of both Hep C treatments, recently slashed the price of each drug from around $100,000 to $24,000 per course of treatment.
Ultimately, the news agency says the NPFF will be as expansive as the similarly named National Preferred Formulary (NPF), which covers more than 3,000 branded and generic drugs.
When new generic drugs are introduced, Express Scripts will consider it for inclusion on the NPFF. If it makes the cut, that means the brand-name drug will be left out in the cold.
“If appropriate, the authorized alternative product will be added to the Flex formulary with preferred or possibly non-preferred status,” the press release notes. “The innovator brand-name product, and potentially other products in the therapy class, then will be excluded from coverage.”
If your employer or government-sponsored plan works with Express Scripts, they’ll have the choice to either opt in to NPFF or to continue offering branded drugs, which may have a rebate.
However, if you choose to pay cash out-of-pocket rather than going through insurance, you’ll have immediate access to the new lower pricing when 2019 arrives.
Limiting the role of manufacturer rebates
Part of what Express Scripts is trying to do is limit the role that drug manufacturer rebates play in deciding which medications get to the end consumer.
As we’ve explained in previous articles, PBMs like Express Scripts and other receive what can only be described as financial kickbacks from the drug companies on certain medications.
These kickbacks, which the PBMs reportedly pocket part of before sharing the rest with the insurer, are euphemistically called “rebates” in the parlance of the industry.
A big rebate may mean a certain drug gets listed as a Tier 1 drug, which would put it on the cheapest pricing rung when you need a prescription. And cheap pricing, of course, puts Tier 1 drugs in direct reach of the largest number of customers across a variety of income levels.
That widespread availability, in turn, creates additional demand for the drug — simply because it is among the cheapest medications on the market.
So by giving preferred status to authorized alternatives, Express Scripts is hoping to shift the economics of the prescription-drug business.