Express Scripts’ Formulary Management Process

Clinical appropriateness, not the cost of a drug, is the first consideration in formulary decisions, said Katie Thompson and Katie Deckelbaum of Express Scripts.

Express Scripts’ formulary development team takes a proactive approach to tracking the drug pipeline to understand the new therapies that may become available and their market impact. Clinical and business teams are reviewing the data in the literature and working to understand the financial impact of those new therapies, Katie Thompson, Pharm.D., senior director, formulary solutions at Express Scripts said at the 2021 Pharmacy Benefit Management Institute® Annual National Conference.

“We are not waiting for a drug to be approved to begin the process. We know our clients expect us to be ready for what’s coming next. We want to be able to understand what formulary strategies we can implement and what clinical programs we can devise,” she said.

Express Scripts is also having conversations earlier with pharmaceutical companies to better understand the data they have, what prescribers they are interfacing with and where they see the drug fitting in, especially in categories where there will be significant impact.

The organization employs a multilayer process to determine which therapies are appropriate and to include on its various formularies. “We are plan sponsors and health plans to provide affordable access to clinically sound, high-quality pharmaceuticals. Formulary management is one way to achieve this result. We are always looking for ways to unlock new value but we need to balance care and cost.”

She stressed that clinical reviewers in both the internal therapeutic assessment committee and the external P&T committee make formulary recommendations based on clinical review only and they don’t have take contracts or rebates into consideration. A separate team, the value assessment committee, makes those considerations, and firewalls exist between the clinical and the value assessment committees.

The organization employs a continuous monitoring process to be up-to-date on the latest clinical research and guidelines. “Doing right by our patients and doing right by our clients is of utmost importance,” said Kate Deckelbaum, RPh, VP, consultant relations at Express Scripts.