PBM calls on insurers to battle with drug makers over costs
Express Scripts, the largest pharmacy benefits manager (PBM) in the US, has recommended that insurers and employers should cover fewer drugs for many inflammatory conditions. In recent years, drugs such as Humira and Enbrel, taken by millions of people for conditions like rheumatoid arthritis, have doubled, making them the costliest drug class in the US according to some calculations. The move by the PBM aims to put pressure on pharmaceutical manufacturers to lower prices. It comes after out of pocket contributions for EpiPen prescriptions jumped from $6 a box to $123 causing a furore and putting both manufacturers and PBMs in the spotlight.

“This is a category of drugs that are used for crippling, very painful conditions, yet they don’t affect huge numbers of people,” said Dr. Glen Stettin, the chief innovation officer at Express Scripts. The rising costs, he said, are due less to a rising number of patients who need the products and “much more because of the increase in the prices of these medications.”

The approach is the latest effort by insurers and drug benefit managers to more closely manage drugs in high-cost diseases, limiting which ones are covered or requiring patients to take additional steps to get approval for certain products. In 2014, Express Scripts shook up the market for hepatitis C drugs when it required its patients to use a new treatment by AbbVie rather than more expensive competitors. It made similar moves last year with the approval of expensive new treatments for high cholesterol.

Like those previous efforts, the effort for inflammatory conditions will most likely help the company’s mail-order specialty pharmacy, Accredo. Express Scripts said patients getting the anti-inflammatory medications through the new program would need to use Accredo, not a competing pharmacy, giving the service a bigger base of customers.

As a drug benefit manager, Express Scripts provides services like negotiating with drug companies and approving or denying drug claims. The new program is voluntary for employers and insurers who use the company, but its recommendations are usually widely adopted.

Humira, made by AbbVie, and Enbrel, made by Amgen, each carry a monthly list price of just over $4,000, and each have increased those prices by about 130 percent from 2011 to 2016, according to the Gold Standard Drug Database compiled by Elsevier Clinical Solutions. That price does not include rebates that the manufacturers negotiate with insurers. Express Scripts said that the actual monthly cost of anti-inflammatory drugs, before the new program, was about $3,000.