Express Scripts to Give Refunds if Patients Don't Stay on Expensive Drugs

The nation’s largest pharmacy benefits manager (PBM), Express Scripts, today announced a program that will offer refunds for payers when patients abandon expensive biologic treatments for inflammatory conditions, such as rheumatoid arthritis.

Called the Inflammatory Conditions Care Value Program, it is designed to control costs that climb out of control and frustrate payers when they shell out an average of $3036 for a 30-day prescription, only to see 21% to 36% of patients stop therapy within 90 days. When this happens the patients have gained little medical benefit, but their payer is stuck with the bill.

“Painful inflammatory conditions like rheumatoid arthritis can cripple patients and obliterate payer budgets,” said Glen Stettin, MD, senior vice president and chief innovation officer at Express Scripts. “By finding creative ways to take better care of patients and protect our clients’ budgets, Express Scripts is uniquely tackling one of the biggest health challenges facing our country today.”

Patients may stop biologic therapy due to side effects, such as flu-like symptoms, headaches, or skin reactions at the injection site. Express Scripts said in a statement that it has previously offered refunds for early discontinuation of a single medication, but this approach represents the first program that spans a class of preferred medications to treat multiple diseases, including Crohn’s, psoriasis, and other conditions.

According to Express Scripts’ statement, roughly 10 million Americans live with an inflammatory condition. Biologics became the most expensive class of therapy in 2015, accounting for 9.8% of US pharmacy spending. If current trends continue, the PBM estimates that spending on these medications will double by 2018.

Stettin said the new program is part of a broader effort to better manage these very costly medications, starting with more effective use of pharmacists to work with patients when prescriptions are filled. Use of Express Scripts’ specialty pharmacy and its resource center leads to adherence rates that are 8% higher.

Management across the class of medications and sharing risk addresses a one of employers’ biggest complaints, Stettin said: paying for pricey drugs that don’t help patients get healthier. “Express Scripts is minimizing our clients’ financial exposure if a patient needs to switch medications or discontinue treatment early,” he said.

In an interview last year with The American Journal of Managed Care, Stettin discussed the fact that the price of some specialty medications had reached the point that there was simply less margin for error. “The slightest deviation from best practice guidelines has significant implications for cost,” he said at the time.