It has become tradition at Advera Health to look closely at the annual formulary exclusions that the large payers such as Express Scripts introduce every August. Using our safety scoring and costing algorithms we are able to quickly provide a top-line view into the effects of their decisions. 

In 2013 we asked why Express Scripts’ decision to remove drugs from their formulary was news and followed that with a specific example in the multiple sclerosis space where we thought that they made the wrong choice.

In 2014 we described how August is now one of the scariest months of the year for pharma. That year Horizon Pharma disclosed in their 8-K that the exclusions of Vimovo (naproxen/esomeprazole) and Duexis (ibuprofen/famotidine) cost the company 30% of their revenue. We also noted that it seemed that post-marking safety was starting to become a factor in formulary decisions. Express Scripts excluded the DPP-4 Nesina in favor of Onglyza, which matched the analysis we included in a Special Report on Diabetes that we put out at the time.

In early 2015 we wrote an opinion piece discussing how exclusivity deals often put immediate cost savings before long-term medical concerns.

In August of 2015 it seemed that the tide was turning in favor of safety and against the costs associated with adverse events. We demonstrated that the average downstream medical costs associated with Express Scripts preferred drugs were on average less than the costs of the excluded ones, resulting in an average savings of $7.70 per prescription. We estimated that it could have equaled close to $108 million in total savings to the healthcare system.

However, we also estimated in a separate analysis that CVS’ decision to cover Farxiga rather than Invokana in 2016 could cost the healthcare system $170MM.

Now, here we are in August of 2016 and Express Scripts has once again issued its formulary exclusions. According to an Express Scripts blog post, the National Preferred Formulary (NPF) will exclude 85 drugs this year. The changes it states, will affect 0.12% of its 25 million members and will save plan sponsors $1.8 billion throughout the year.

That’s a big number, but based on our RxCost® analytic (methodology published in the Journal of Managed Care and Specialty Pharmacy) the true savings should be looked at more closely.  

For example, as you can see in the table below, we continue to show that the choice to cover Viekira Pak to be a poor one. Sovaldi, Olysio, and Daklinza, all excluded, are safer choices according to our data.

Average Downstream Medical Cost Differences for Selected Express Scripts Formulary Drug Classes

The downstream medical costs of the Preferred TNF Antagonists should also be examined. Cosentyx, Stelara, and Xeljanz have larger harm costs than the excluded Orencia and Simponi.

The data show that Express Scripts continues to provide a medical cost savings for DPP-4 drugs, keeping the highest harm cost in class Nesina excluded. However, our data suggest that further downstream medical cost savings could be seen by adding Onglyza to the preferred alternative list.

This quick analysis only scratches the surface of what insights can be found using Advera Health’s Evidex platform. Get in touch with our team today to take a look for yourself.


Jim Davis, EVP Advera Health Analytics


Topics: Drug Safety, Managed Care, Evidex

Jim Davis

Written by Jim Davis

As Executive Vice President, Jim is responsible for the commercialization strategy for Advera Health Analytics.