In my post last week, I wondered why Express  Scripts’ decision to drop certain medications from its formulary was such big news.

In response, a reader was kind enough to send me the exclusion list. 

After performing our formulary optimization analysis on the exclusions, I think that some of the decisions were made without any insight into the true medical cost.

Now, don’t get me wrong.  I applaud Express Scripts for taking a proactive role to change and exclude certain medications from their formulary.  This should be happening at every managed care organization on a regular basis - BUT the full scope of available data must be used to inform these decisions.

As I have mentioned in past posts, we are data geeks at AdverseEvents, not clinicians. We present actionable data that can be used to make informed decisions.

That said, let’s look at Express Scripts’ action on the Interferons used to treat relapsing MS.  They removed Betaseron from the formulary, but kept Avonex,  Rebif and Extavia.  Yes, all of these have different injection regimens, but they can mostly be used interchangeably and have common label warnings.

It’s not surprising that Express Scripts chose to drop one of these medications – we would have advised the same.

However, our data shows that they may have dropped the wrong one.

When we provide data to our clients to assist in formulary decisions, we look at three major things:

  1. Plan Cost (how much the medication costs the plan, net of co-pays and deductibles)
  2. Medical Cost (what the differential downstream costs are for the medications)
  3. Safety Profile (what our experiential data shows about real world outcomes and quality of care).

From work we’ve done, we know that the Plan Costs and Safety Profiles of these Interferons are substantially similar.  Plan Cost is a data point we collect from our Formulary Optimization clients and it shows how much money they are paying on a per prescription basis for each medication.  Safety Profile is something we determine through our proprietary RxScore system.  RxScore is an algorithmic scoring model that ranks and compares medications based on post-marketed safety reports and signals.

Where these drugs diverge is on the Medical Cost.  Using our RxOutcome analytic, we know that Avonex has a Medical Cost more than 4X that of Rebif and more than 2X that of Betaseron.

All in, that means that Express Scripts stands to lose money by shifting people off of Betaseron and onto Avonex.  How much money?  We estimate about $270 per prescription.  That adds up to a whole lot of money when you’re covering millions of people.

Should formulary decisions be all about money?  Of course not.

Is Avonex a better medication choice than Betaseron or Rebif?  That’s a question for clinicians and specific to each patient.

But when you have medical equivalents with similar safety profiles (from both clinical trials and post-marketed safety data) and you’re taking steps to reduce formulary redundancies anyway, it sure seems that taking the financial implications into full account is an appropriate thing to do.

For more information about the Formulary Optimization work we do, click here.

 

 



Brian Overstreet

Brian Overstreet

President

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Topics: Managed Care, Drug Safety

Brian Overstreet

Written by Brian Overstreet