Express Scripts, CVS Health formulary changes affect one in two Americans
From the article:
In August CVS Caremark (now CVS Health) and Express Scripts released their formulary restrictions, effective January 2015. CVS Health and ESI, which together cover nearly half of all Americans, make formulary decisions that influence roughly 150 million covered lives. Thus, pharmaceutical manufacturers are in a must play position to have any chance at maintaining a presence in the brand medication market.
CVS Health’s closed formulary has been in place for several years. For 2015, CVS Health continues its aggressive removal process with no signs of easing up on formulary management efforts. CVS Health removed an additional 22 medications from its formulary, increasing the total to approximately 100. A few of the exclusions include: Byetta (diabetes); all diabetes testing strips and kits except for OneTouch brands; Rebif (specialty treatment for MS); Lunesta (sleep aid) and Levitra (erectile dysfunction). CVS Health is also planning to exclude one of the newer Hepatitis C treatments in 2015. Without significant discounts on both products, one treatment will likely be removed, depending on the price of the product and the latest agents (i.e. Solvaldi).
ESI removed 25 products this year, bringing the excluded medication list to more than 60. While only in its second year, the impact of ESI’s changes is significant as some major product classes are now tightly managed and the effort to remain a brand formulary product is considerable. Five of the excluded products are from four new therapeutic classes
Most PBMs are offering a restricted formulary, meaning rebates will have a larger impact on plan savings versus other discounts. Manufacturers wanting to remain competitive will need to ‘pay to play’, even if it means simply being covered on a formulary.
As pointed out in this article.. these PBM’s are removing medications that they will pay for.. a few each year… Since 80% + of all prescriptions are now filled with generics.. they are targeting brand name drugs – with no available generic – and NEW THERAPIES… The profits from this segment of available drugs pay for Research and Development of new therapies to come.. Guess what is going to get LESS FUNDING ?
So are we moving away from providing the best therapies and outcomes.. or just the best therapies and outcomes for the LOWEST PRICE ?
Since these two PBM’s (ESI & CVS Health) right now control HALF of the populations access to medications.. Will we figure out what is happening to us and our quality of life before our asses become COOKED ?
Filed under: General Problems
William….my husband has a, fairly low tesrosterone level. He started on cyprionate inj which brought it up to normal and was doing well. Insurance only paid for 1ml vials. Big push for gels made injection pretty much scarce. I could find multi dose vials but not covered because more than a month supply and because im a RPh out of work in a flat market where relo is impossible at this point buying multi dose vial is out of question. We tried 2 kinds of gels….useless, his levels went down to pre inj! We tried PA for the ethanate form, just got back the DENIAL, insurance says gels should be sufficient even in light of lab evidence they are not for him. Doses were even doubled. So William you tell me they always approve the PA with evidence of medical need. He is currently going without until I can afford and jope I can still find someone carrying a multdose vial of injectable. He also has bipolar and his current brand psych med is not approved, so I thank the lord and the reps for supplying his psychiatrist with boatloads of samples that we can get a monts supply. That is until his insurance decides what they are going to do. BTW we do not go thru Caremark or Express, its another PBM. Id like to ask you if you have experince having to fight the system for a family member with a serious illness because I do all the time and it doesnt come out easy peasy all the time. Thats when I get the most frustrated and pissed off for my husband but frustrated and disgusted at PBMs for the patients. Thank you for allowing me to express my side to you.
steve, if you worked as a pharmacist, you would probably know that there are alternative drugs to all those drugs that are excluded. you should also know that pharmaceutical sales reps are out there promoting their expensive, brand name drugs while low cost, high quality generic products are available in most common therapeutic classes. doctors, like the rest of us, tend to remember products that are promoted by cute sales reps who bring them food but forget about those products that have been around for many years that nobody is talking up anymore.
you would probably also realize that there is a system in place where an appeal can be filed to get non-formulary drugs covered. its a simple procedure that can be initiated by the pharmacist. if there is a VALID MEDICAL REASON why levitra is necessary and viagra or cialis just won’t do the job, the plan will probably relent and authorize payment for the non-formulary product. of course, if something isn’t covered that you really, really want, you always have the option of paying for it on your own.
the system works to try to reduce costs even as its putting money into the pockets of shareholders. generally, it works well. reducing costs is something that benefits us all. i’ve never been a big fan of PBM’s but in this case, you’re misleading your readers.
and for those of you who are fans of the ACA… if you think things are expensive now, just wait until its free.