- Express Scripts, the nation's largest pharmacy benefits manager (PBM), is moving towards indication-based pricing to determine coverage, with an initial focus on cancer drugs this year. Next year, Express Scripts will use the same method—linking coverage with the strength of evidence from studies—for inflammatory and arthritis drugs.
- The PBM also aims to respond fast to price increases, such as Turing's infamous price hike for Daraprim. Currently, it can take several months to shift to a generic alternative or cheaper brand option. Express Scripts' goal is to respond within weeks.
- For several years, Express Scripts and others have attempted to save money and limit spending on high-priced drugs by mandating prior authorization and limiting drug choices. But the national focus on drug pricing over the past year has empowered the PBMs to act more aggressively.
2015 could mark a tipping point in the U.S. healthcare system. High-price pharmaceuticals and aggressive price increases have prompted a harsh backlash from lawmakers and payers, seemingly shifting the paradigm for pricing drugs and getting them covered.
With 85 million people under its coverage umbrella, Express Scripts has leverage to further shift the system toward a more price-conscious approach. Indication-based pricing and fast responses to price increases could set the tone for other PBMs.
Express Scripts hopes to move more quickly in response to price increases, such as Valeant's increase in the prices of Isuprel and Nitropress last year. Steve Miller, Chief Medical Officer, Express Scripts, said: “We are going to be able to act within weeks, instead of months or longer," said Steve Miller, the chief medical officer at Express Scripts, in comments reported by Bloomberg.
While the primary focus will be on cancer drugs, Express Scripts also plans to also address other therapeutic areas. One area due for scrutiny and the implementation of indication-based pricing are the anti-inflammatory drugs, including Humira, Enbrel and Remicade, Bloomberg noted.
Earlier this month, a biosimilar version of Remicade was approved by the FDA. Although Inflectra has not yet launched and pricing has not been set, its approval means that eventually will be able to push patients towards a cheaper treatment option for Crohn's disease, rheumatoid arthritis and other inflammatory, immune-mediated conditions. Other biosimilars in the wings could give new options to expensive, branded biologics and lower costs for PBMs like Express Scripts.