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Benefits plans excluding more drugs as costs rise


Express Scripts, CVS Health and Medicaid rank among the prescription benefit managers banning specialty drugs from health plan coverage in an effort to keep costs down, Bloomberg reported.

Express Scripts will exclude 66 brand-name drugs from its main formulary, or list of drugs that it covers, in 2015. This marks an increase from 48 in 2014. Likewise, CVS will exclude 95 drugs, up from about 70 in 2014.

Benefits firms push back against high-priced drugs when less expensive clinical equivalents are available, Express Scripts Chief Medical Officer Steve Miller told Bloomberg. For example, in 2014 the company decided to stop covering Advair, which can cost more than $370 per month, after determining that less expensive competing drugs treat asthma just as well. Advair maker GlaxoSmithKline offered a lower price, though, and now the drug is back on Express Scripts' main formulary in 2015.

Meanwhile, state Medicaid plans increasingly are limiting their coverage for the hepatitis C drug, Sovaldi, which costs $84,000 for a 12-week dose. Many states will only cover the drug for patients with severe liver damage and will limit coverage for patients with recent substance-abuse problems, according to Bloomberg.

America's Health Insurance Plans have called out pharmaceutical companies for taking advantage of insurers by pricing drugs such as Sovaldi at an "astronomical level," FierceHealthPayer previously reported. Use of Sovaldi and other high-priced drugs--including Rebif, a multiple sclerosis treatment with a $5,000 price tag for a four-week supply, which CVS has excluded from its main formulary--have contributed to an expected 12 percent increase in prescription drug costs in 2014.

In addition to excluding drugs, health plans increasingly require pre-approval from insurers before authorizing prescriptions for specialty drugs. However, doctors and pharmaceutical companies alike say that this creates bureaucratic bottlenecks and doesn't always give patients the treatment they need, according to Bloomberg

For more:
- read the Bloomberg article

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