Arthritis Foundation Confirms Drug Access for Express Scripts Customers

January 13, 2014

Discussions at the end of the year between Arthritis Foundation CEO Ann M. Palmer and Express Scripts, a leading pharmacy benefit management company, led to clarification of the company’s general formulary policies, with easing of a specific time-frame restriction.

At the end of 2013, Express Scripts, based in Bellerive, Mo., notified patients and doctors that the company’s new 2014 formulary would, for the first time, exclude five disease-modifying and biologic drugs used to treat inflammatory and autoimmune types of arthritis – Cimzia, Simponi, Simponi Aria, Stelara and Xeljanz.

Drug exclusion is a significant step beyond the common formulary distinctions of “preferred” and “non-preferred” drugs. Preferred and non-preferred status indicates different levels of out-of pocket but still discounted costs to plan members. In contrast, consumers must pay 100 percent of the non-discounted cost of excluded drugs.

“The Arthritis Foundation’s goal is to minimize the barriers people face in getting effective treatment,” says Palmer. “What works for one patient may not work for another. That’s why the Arthritis Foundation supports access to a full range of treatment options.”

During discussions, Express Scripts affirmed its commitment to the health and wellbeing of patients. It stated that even though those five drugs will remain excluded from the company’s standard formulary, plan members will still have access to them at the non-preferred, but still discounted pricing in certain situations. Those who are on the excluded drugs at the end of 2013 may continue treatment without interruption, paying the non-preferred, or third-tier, copay, rather than 100 percent of the cost, as is typically required for excluded drugs. At first, Express Scripts required that those patients had to be “started and stabilized”on the therapies 90 days or more before Jan. 1, 2014, but later agreed that there would be no defined period of time for prior treatment and no special application for continuance required

Express Scripts further explained that during the 2014 plan year, patients who do not achieve adequate symptom or disease control on one of the formulary’s preferred drugs – Enbrel or Humira – can, with their physician, request a formulary exception (access to a non-formulary drug) at a discounted, tier 3, or non-preferred copay.

In addition, Express Scripts confirmed its policies and processes related to requests for formulary exceptions, noting that responses will be given within two business days. Rejections of requests can be appealed, and access to an excluded drug can be given in the“rare instances” when “clinically justifiable,” according to the company.

See the Arthritis Foundation’s formal request to Express Scripts, and Express Scripts’ response.

“The introduction of biologic and disease-modifying drugs in the past 15 years has brought tremendous progress in limiting the disabling impact of rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis and many other inflammatory diseases,” says Palmer. “But the window for preventing joint damage is limited. People with arthritis need to be able to make timely decisions with their physicians on the best treatment for them.”

The Arthritis Foundation has concerns about patients’access to treatments, as pharmacy providers nationwide implement cost-cutting measures. “We plan to closely monitor not only Express Scripts, but other providers as well, both in the policies they create and in how they actually act on exception requests that may be submitted,” says Palmer

We want to hear from people covered by the Express Scripts formulary that excludes those five drugs– Cimzia, Simponi, Simponi Aria, Stelara and Xeljanz. If you have been taking one of the drugs or if your doctor recommends that you take one, please let us know whether you have been granted full access to them, with a timely response on the request for exception, at a discounted plan cost or not. Contact us at [email protected]. Please put “Express Scripts” in the subject line.

In addition, we want to hear from people who have experienced barriers to treatment for arthritis. While we cannot address individual cases, we are monitoring trends that affect access to health care for all people with arthritis. Please use email address above, with “Access to Care” in subject line.