Help Patients Navigate the Challenges of Formulary Changes with RxLink

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Patients and clinicians are always challenged by formularies—the list of drugs covered by insurance along with what the patient is expected to pay for covered drugs. 

These formularies are determined by PBMs, and the three largest PBMs each excluded around 600 drugs from coverage in 2023. This means that patients either need to pay for these excluded drugs out of pocket at retail price or find an alternative medication to treat their condition. Staying on top of these exclusions is simply impossible, for both patients and their physicians.

This is challenging when a patient is trying a new medication, but can be devastating when a patient experiences a formulary change to an existing chronic medicine. 

Patients are hit exceptionally hard when a chronic medication is taken off formulary—
costs can skyrocket without warning.

If a drug is a “preferred brand medication,” the typical co-pay is $37 for a 30 day supply. If the drug is removed from formulary, the patient can find their next fill costing $1,000 or more.

Every year, new drugs are dropped from formulary on January 1.

According to the consulting firm PSG, Express Scripts removed 40 drugs from their formulary on January 1, 2024. They were not alone: CVS removed 39 and Optum removed 22.  

The impact was not limited to specialty drugs. Both CVS and Optum dropped Advair, a common retail medication indicated for asthma and COPD. 

RxLink can provide continued affordability to drugs no longer on formulary

Let’s use Advair as an example. A patient with preferred brand coverage would have paid around $37 out of pocket for the branded version of Advair HFA. With the formulary exclusion, they would have been told their out-of-pocket cost is $443.* 

RxLink aggregates and analyzes all available affordability options for medications, including discount cards, manufacturer offers, and generic alternatives. Then, RxLink factors in a patient’s preferred pharmacy and insurance to provide a Med Map™ of different ways to save. 

RxLink delivers the best options for patient affordability in simple, actionable form
via SMS and our easy-to-use web app 

Even for patients with private commercial insurance, RxLink will offer a better price for the patient nearly two-thirds of the time. For the Advair HFA patient, RxLink would surface two options to save the patient money:

  • A discount card to provide access to the branded medication for $31.17
  • A generic option with a discount card for $25.82

Each of these options is less than the previous out of pocket of $37 before the formulary exclusion and saves hundreds versus the off-formulary retail price! 

If you are a payer or health system looking to help your patients manage the impact of PBM-driven formulary changes, e-mail us at info@rxlink.com to start the discussion!

 

*All prescription costs cited for Advair HFA are for one inhaler 45/21 mcg per actuation at CVS in Suburban Philadelphia, PA.