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The Pharmacy Benefit Management Team: Helping Patients Access Affordable Prescription Drugs Safely and Efficiently

Pharmacy benefit managers (PBMs) like Express Scripts are uniquely positioned to help patients in numerous ways.
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Medicine – and prescription medications in particular – can be confusing. That’s why clinicians at Express Scripts’ mail order pharmacy are always on the lookout for potential problems that may hurt patients and are available to answer questions 24/7. This proactive approach can make a huge difference in patients’ lives.

Take Chris Marian, a clinical consulting pharmacist at Express Scripts Pharmacy, who was speaking with a patient about the medication that treats his high cholesterol. The patient mentioned that he was running low on another prescription, which treats his blood pressure, but Marian checked and saw that the patient should have had an ample supply on hand. The patient told Marian he’d been taking two tablets a day – twice the maximum dose and twice the amount prescribed by his doctor. Potential consequences included numerous health issues, such as rapid heartbeat and fainting.

Marian called the patient’s doctor immediately. “My position enables me to make meaningful interventions when needed,” he said. “The doctor confirmed the patient was taking double the maximum dose, and together we fixed it.”

The True Benefit of Pharmacy Benefit Managers

Pharmacy benefit managers (PBMs) like Express Scripts are uniquely positioned to help patients in numerous ways, including automated safety checks that make sure each patient gets the right medicine in the right dose. While many patients may not know much about their PBM team, we impact hundreds of millions of people each day by negotiating lower prices for their prescriptions – and much more.

“PBMs are built to lower prescription drug costs, and we work behind the scenes each day on behalf of the people we serve,” said Amy Bricker, a registered pharmacist and president of Express Scripts. “In fact, PBMs will help deliver $1 trillion in savings on drug costs to patients and health plans over the next 10 years.”

High Quality Medications at a Lower Price

PBM teams help patients spend less for the prescription drugs they need by negotiating with drug manufacturers and by working with their clients (health plan sponsors) to encourage patients to opt for generic medications, which are equivalent to brand-name products but often cost far less: an average copay of $6.61 for a generic, compared with an average copay of $55.82 for a non-specialty brand-name prescription.

Other strategies help reduce the prices of specialty drugs – medicines that are usually injected or infused.  Express Scripts has found that the average annual price of therapy for specialty drugs is $38,000 per patient, 75 times more than non-specialty prescription drugs. Many specialty drugs are biologics, which are complex medications that can cost $50,000 or more annually. PBMs are working to increase the use of biosimilars, which are clinically equivalent alternative medications that typically cost an estimated 35% less than their reference biologics. Biosimilars are beginning to enter the market, with many more on the horizon.

Clinical Results Guide Coverage Decisions

Formularies, such as the Express Scripts National Preferred Formulary (NPF), which Express Scripts developed and offers to its health plan sponsor clients, are important tools that PBMs use to ensure patients have access to the most clinically effective medications at the lowest possible cost. “We develop our formularies based on guidance from independent experts who review the latest clinical data for each drug class to recommend therapies that are proven to help patients most,” said Dr. Christine Gilroy, Express Scripts’ chief medical officer. “These independent experts look solely at clinical safety and benefit, without taking cost into consideration.”

Formularies organize drugs by tiers. The highest tier – preferred drugs – offers the lowest net cost to patients and their plan sponsors. Preferred drugs often include generics, biosimilars, or competitively priced branded medications that offer the greatest clinical benefit to patients and help them save money at the pharmacy.

When multiple clinically equivalent drugs are available to treat a particular condition, formularies force drug manufacturers to compete with each other – which means lower prices for patients and their plan sponsors. For example, Semglee, the first interchangeable insulin, is preferred on the 2022 NPF over the branded insulin product. We expect to achieve $20 million in overall savings this year for patients and their plan sponsors as a result of this change.

Accessible pharmacy solutions for affordable medications

Express Scripts works to make sure that every consumer has convenient access to medicines at the lowest possible cost, offering a robust network of more than 65,000 retail pharmacies – chain stores and independent pharmacists – along with delivery and mail-order options in every U.S. state. Not only do a vast majority of Express Scripts members live within a 15-minute drive from an in-network pharmacy, members can opt for free home delivery of medicines to all 50 states from the Express Scripts Pharmacy. And for patients managing complex or chronic conditions like multiple sclerosis or cancer, Accredo specialty pharmacy and their teams of expert nurses are available to support the home delivery and infusion of medications.

No matter whether the pharmacy is down the street or in a different state, patients can be confident that prescription processing systems pioneered by Express Scripts always perform a series of safety checks designed to minimize the risk of medication errors. Across all PBMs, these steps and systems will help prevent 1 billion medication errors over the next 10 years.

Need Expert Help? Express Scripts is Always There

Getting started on the right medicine is important. Staying on it is crucial. That’s because patients who are adherent – who consistently take their medicine as directed – have better health outcomes and lower overall health care costs.

Across Express Scripts and Accredo, we have more than 1,500 pharmacists who can go in depth to help patients with questions or issues. Many of our pharmacists specialize in specific conditions like diabetes or cardiovascular disease.

For conditions that require complex care management, Accredo has more than 600 field-based nurses who visit patients’ homes, hospitals, and other locations to administer infusions. More than 90% of patients live within one hour of an Accredo nurse.

“For more than 35 years, our relentless focus has remained on lowering the cost of prescription drugs – ensuring that the millions of people we serve get their medications affordably and safely,” Bricker said. “At a time when drug manufacturers are raising prices faster than ever, our work is critically important to help keep prices at the pharmacy counter affordable and health care premiums in check.”