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Express Scripts

Pharmacy benefit manager Express Scripts Holding Co. rewarded two low-priced single source drugs in high-cost categories with preferred status in its 2019 national preferred formulary – Mylan NV’s combination pills for HIV, Symfi and Symfi Lo, and Merck & Co. Inc.’s Zepatier for hepatitis C.

Express Scripts’ national preferred formulary is an option for payer clients and currently covers more than 25m Americans, giving the PBM’s coverage policies significant clout in the employer-sponsored insurance market. The 2019 version was announced Aug. 7.

The PBM highlighted its decisions to prefer Symfi and Zepatier as it announced the 2019 formulary Aug. 7.

Symfi and Symfi Lo (efavirenz, lamivudine and tenofovir disoproxil fumerate) have 40% lower list prices than Gilead Sciences Inc.’s Atripla (efavirenz, emtricitabine, tenofovir disoproxil fumerate), which will be excluded from coverage, Express Scripts said. The Mylan drugs launched in early 2018 as a discount combination treatment option. (Also see "Mylan Plans To Compete In US HIV Market With Two Fixed-Dose Combos" - Scrip, 5 Mar, 2018.)

Zepatier (elbasvir and grazoprevir) is the “low-priced leader” among hepatitis C drugs, Express Scripts pointed out. It will be moved to the formulary’s preferred status next year after being excluded in 2018. Merck announced recently that it will cut Zepatier’s price by 60% beginning this fall. (Also see "Merck's New Pricing Pledge Shows Style Over Substance" - Scrip, 19 Jul, 2018.)

Also preferred among HCV drugs will be Gilead’s Harvoni (ledipasvir, sofosbuvir),Epclusa (sofosbuvir, velpatasvir) and Vosevi (sofosbuvir, velpatasvir and voxilaprevir), suggesting generous rebates from the manufacturer. But AbbVie Inc.’s Mavyret (glecaprevir and pibrentasvir) will be excluded.

Express Scripts emphasis of formulary placement for low-list price products follows its proposal to lower list prices by encouraging firms to market cheaper versions of their products with different NDC codes. (See sidebar.)

But the formulary, like the broader marketplace, continues to reflect an emphasis on rebates to lower net prices. “After clinical considerations, formulary preference is given to high-value therapies with the lowest net cost for clients, achieved through low list price, rebate or both,” the pharmacy benefit manager explained.

A total of 242 drugs are excluded from the national preferred formulary in 2019, up from 196 in 2018. Among 48 new exclusions for 2019 are 37 single-source brands with a high list cost, representing the most single-source brands the formulary has excluded to date. (See chart below.) Express Scripts says the formulary will save health plan clients $3.2bn in 2019.

The PBM will exclude multiple sclerosis drug Extavia, (Novartis AG’ interferon beta-1b) from its formulary in 2019.  But a number of other beta interferons are covered as preferred alternatives: Biogen Inc.’s Avonex and Plegridy,Bayer AG’s Betaseron, and EMD Serono Inc.’s Rebif.

The 2019 formulary does not have any new exclusions in the insulin, anti-diabetic, neutropenia, or respiratory categories. The decisions pertaining to those treatments in the 2018 formulary will remain in effect. (Also see "Express Scripts Boosts Formulary Exclusions With Focus On Multi-Source Brands" - Pink Sheet, 31 Jul, 2017.)

For example,Sanofi’s Lantus (insulin glargine) will remain a preferred insulin while follow-on Basaglar, marketed by Eli Lilly & Co. and Boehringer Ingelheim GMBH, will remain non-preferred.

Mylan’s EpiPen epinephrine products, including its authorized generic, will continue to be preferred and kaleo Inc.’s Auvi-Q and the Impax Laboratories Inc.,Lineage Biomedical Inc. and A-S Medication epinephrine auto-injectors will continue to be excluded.

Amgen Inc.’s granulocyte colony stimulating factor Neupogen (filgrastim) will remain off formulary and two follow-ons, Teva’s Granix (tbo-filgrastim) and Novartis’ biosimilar Zarxio (filgrastim-sndz), will be preferred.

The 2019 formulary does not currently include changes in coverage for anti-inflammatory drugs, such as treatments for rheumatoid arthritis. However, the PBM noted that “treatments for inflammatory conditions are subject to change throughout the year based upon changes in market dynamics, new indications for existing products, biosimilars and new product launches.”

Express Scripts National Preferred Formulary 2019 Single Source Brand Exclusions

Drug Class


Preferred Alternatives


Pradaxa, Savaysa

Eliquis, Xarelto

Parkinson’s agents

Neuro Patch

pramipexole tablet, pramipexole ER tablet, ropinirole tablet


rasagiline, selegiline

Multiple sclerosis beta interferons


Avonex pack, Avonex Pen, Betaseron, Plegridy, Rebif, Rebif Rebidose

Blood glucose meters and test strips

Abbott (Freestyle, Precision)*, Bayer (Breeze, Contour)*, National Medical (Advocate)*, Omnis Health (Embrace, Victory)*, Roche (Accu-Chek)*, Trividia (Truetest, Truetrack)*, Unistrip* and all that are not Lifescan brand

Lifescan (OneTouch)

Combination Patches

Climara Pro


Corticosterids (rectal)


hydrocortisone enema, Uceris foam

Factor VIII Recombinant Products

Eloctate, Recombinate, Xyntha, Xyntha Solofuse

Advate, Adynovate, Afstyla, Helixate FS, Kogenate FS, Kovaltry, Novoeight, Nuwiq

Gonadotropin releasing hormone agonists for precocious puberty

Lupron Depot-ped.


Gout therapy

Duzallo, Zurampic

allopurinol, probenecid

Growth hormones

Humatrope, Nutropin AQ, Nuspin*, Omnitrope*, Saizen*, SaizenPrep*, Zomacton*

Genotropin, Norditropin Flexpro

Hepatitis C

Daklinza, Mavyret, Olysio*, Sovaldi*

Epclusa, Harvoni, Vosevi, Zepatier*

Hereditary angioedema


Cinryze, Ruconest

HIV antiretrovirals


Biktarvy, Genvoya, Odefsey, Stribild, Symfi, Symfi Lo, Triumeq

HMG & Cholesterol Inhibitor Combinations

Altoprev, Zypitamag*


atorvastatin, lovastatin, rosuvastatin, simvastatin, Livalo

Human Chorionic Gonadotropin

Chorionic gonadotropin, Pregnyl

Novarel, Ovidrel

Irritable bowel syndrome and chronic constipation agents

No drugs will be excluded in 2019

Amitiza, Linzess, Trulance*

Long-acting beta agonist nebulized



Long-acting opioid oral analgesics

Embeda, Oxycodone ER*

hydromorphone ER, morphine sulfate ER, oxymorphone ER, Hysingla ER, Nucynta ER, Oxycontin

Miscellaneous topical dermatological agents

Alcortin A

hydrocortisone, mupirocin

Nonsteroidal anti-inflammatory drugs

Fenoprofen (capsule), Fenortho, Nalfon

fenoprofen calcium (tablet/generic), diclofenac, indomethacin, ibuprofen, meloxicam, nabumetone, naproxen

Ophthalmic anti-allergic

Alocril, Alomide, Emadine

azelastine drops, cromolyn drops, olopatadine drops, Alrex, Bepreve, Pazeo

Ophthalmic anti-inflammatory

Flarex, FML Forte, FML S.O.P., Maxidex, Pred Mild

dexamethasone drops, fluorolometholone drops, prednisolone drops, Lotemax

Topical antiviral agents

Xerese cream

acyclovir (tablet/capsule), famciclovir tablet, valacyclovir tablet, Zovirax cream

Topical corticosteroids

Topicort spray, Verdeso foam

desonide .05% (cream/lotion/ointment), desoximetasone .25% (cream/ointment)

Weight loss agents

Contrave ER, Qsymia*

benzphetamine, diethylpropion, phentermine

*Current 2018 exclusion in this class.

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