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Express Scripts Cut HIV Drug Formulary - AIDS groups criticize Express Scripts for excluding several HIV medicines
  This is a shot across the bow, a test by Express Scripts now that is being watched by other insurers and thus cannot stand, the is unacceptable. The next thing is other insurers will follow & our HIV drug formularies will fall apart, we will be left with a limited formulary of ART drugs. Express Scripts says this is based on cost savings: "An Express Scripts spokeswoman wrote us that "our job is to drive to lowest net cost. The preferred alternatives are less costly either by list price or rebate or both. ... We now, finally, have leverage in this therapy class to drive discounts as we do in other therapy classes." This subjects us to whatever drugs are less expensive will be the last ones included in formularies allowing insurers to whittle down our choices to the few they choose. They do not care that ART regimen selection is based on what the patient tolerates & is effective, not based on cost & not based on a selection process that excludes the doctor & patient from a decision. Jules Levin
By Ed Silverman @Pharmalot
June 6, 2019
A recent decision by one of the largest pharmacy benefit managers in the U.S. to exclude several HIV medicines from its list of drugs eligible for insurance coverage has angered AIDS advocacy groups, which argue the move may harm patients.
In two separate actions over the past few months, Express Scripts excluded seven HIV medicines for anyone starting treatment. The pharmacy benefit manager explained that less expensive alternatives are available and its decisions were supported by clinical guidelines. The company also noted the drugs remaining on its national formulary appear on federal guidelines for most patients.
The moves, nonetheless, prompted an angry response.
The exclusions are "bad medicine" that will "hinder the treatment of HIV and jeopardize public health," Carl Schmid, the deputy executive director of The AIDS Institute, a nonprofit, nonpartisan group, wrote in a June 3 letter to Steve Miller, the chief clinical officer at Cigna (CI), the big insurer that recently purchased Express Scripts.
He argued that because HIV is a complex condition to treat, experimenting with different medicines on a case-by-case basis is often necessary to determine which drugs work best and also do not interact with still other medications. By keeping some drugs off the formulary, he added, interruptions in care may occur, which may be exacerbated by changing prescriptions or increased co-payments.
Express Scripts allows doctors and patients to seek exceptions to formulary coverage, but the group contended the changes could undermine
guidelines issued in 2017 by the Centers for Disease Control and Prevention, which pointed out that consistent treatment and patient adherence can be best achieved when care is uninterrupted.
"Patients need access to HIV (medicines) quickly and exceptions processes are rather long and people just give up, something we don't want to happen," Schmid told us. We should point out the letter sent by the advocacy group to Express Scripts did not reflect the fact that the formulary changes will not alter coverage for existing patients, an issue the group raised initially.
The dispute occurs amid growing anxiety and political tumult over the rising cost of medicines and, at the same time, an ongoing push by the AIDS community to confront policymakers, drug makers, and insurers to widen access to treatment. In this instance, the move by Express Scripts underscores the tension surrounding each battle.
Express Scripts, for instance, noted that one of the excluded drugs, Atripla, cost 40% more than two of the alternative HIV medicines placed on its preferred formulary list. Such explanations are in keeping with repeated arguments by pharmacy benefit managers that formularies are useful tools to wield in keeping spending down for prescription drugs.
Schmid, however, argued that, in some instances, the medicines Express Scripts now categorizes as preferred alternatives are actually more expensive than the excluded medications. As examples, he pointed to the list prices for Biktarvy and Genvoya, which are higher than Atripla and Delstrigo. For this reason, he suggested Express Scripts excluded some medicines to capture rebates from drug makers.
In general, this is a contentious point in the wider debate about drug pricing. Drug makers say they must raise list prices to cover larger rebates sought by pharmacy benefit managers and win favorable formulary placements. Pharmacy benefit managers argue they pass long the vast majority of rebates to health plan clients and that drug makers raise list prices to pad their profits.
An Express Scripts spokeswoman wrote us that "our job is to drive to lowest net cost. The preferred alternatives are less costly either by list price or rebate or both. ... We now, finally, have leverage in this therapy class to drive discounts as we do in other therapy classes, and we have carefully made a few exclusions that preserve access while helping to lower costs in one of the costliest therapy classes for payers and patients."
But Tim Horn, who heads the medication access and pricing program at the National Alliance of State and Territorial AIDS Directors, which represents public health officials who administer HIV and hepatitis programs, was not convinced.
"This is certainly one of the most aggressive examples of insurers or pharmacy benefit managers moving to control drug pricing through formulary design," he wrote us. "A mid-year formulary update that doesn't include some newer drugs and drops some older products is something we really haven't seen before. ... The end result is one or two products that really should be available to people living with HIV being cut, or left off."
We should note that The AIDS Group accepts funding from drug makers, among others, and one of its board members is Gregg Alton, the chief patient officer at Gilead Sciences (GILD), which has three drugs being excluded from the formulary. However, other Gilead drugs appear on the preferred list.
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