Express Scripts Settlement on Statin Switches

I don’t know the insider details, but I am certainly familiar with the original program in 2005/2006 which targeted users of 3rd tier branded cholesterol (statin) drugs to get them to move to a lower cost agent which could either be a brand or generic drug on formulary (obviously wanting it to be the generic).

Apparently Express Scripts settled with 28 states for $9.5M associated with their program.  I would guess there were several issues:

• Switches within this class might require follow-up physician visits and/or lab work to be done.  That could increase copays for the patient and/or drive up plan costs.  How clearly that was explained could be an issue?
• Depending on timing some of these switches might have occurred right when Lipitor was moved off formulary.  It would have then been more expensive for the plan sponsor, but I believe all the clients would have signed off on this knowing that they would save money over the initial 12-month period.
• Depending on when this is from, they moved Lipitor back on formulary for 2008 which might mean some people were bounced around different formulary agents.  (But, I can’t imagine this was already identified and settled.)

It basically appears to be a communication issue.  Was the right information disclosed to the right person at the right time with the right amount of detail?  And, even if it was, is it worth fighting it?

From a patient perspective, I would hope that this doesn’t prevent my health plan / PBM from reaching out to me to tell me how to save money.  I spend a lot on health care each year and hate to believe that there aren’t ways to save money.

From a PBM / plan perspective, I wouldn’t be discouraged.  This just continues to clearly layout the rules about what needs to be done.  There are still plenty of opportunities, but they need to be designed the right way with the right information included in the communications.  There is nothing there that is not achievable or unreasonable.