National Preferred Formulary: Access Meets Value in HIV Treatment

Our National Preferred Formulary continues to deliver savings with minimal member impact, leading to more favorable medication adherence.
Access meets value

Our job is to make sure every patient gets the medicine they need, safely and affordably. For people with HIV, our National Preferred Formulary provides coverage for the vast majority of HIV medications -- 63 in total -- including treatments recommended by the Department of Health and Human Services for initial therapy.

The current state of HIV treatment options is incredibly promising for people living with HIV. Antiretroviral regimens are keeping the virus in check, while other treatments prevent the transmission of HIV for at-risk people.

Among the greatest challenges for HIV treatment is cost, but even there we are seeing potential. The wide range of highly effective agents currently available, along with new drugs coming onto the market, have created competition in this class that hasn’t existed before, allowing us to provide patients with the best options therapeutically and more cost-effectively.

In January 2019, we had an opportunity to exclude four therapies that had lower-cost alternatives, including Atripla, which costs 40% more than preferred alternatives Symfi and Symfi Lo. Beginning July 1, we will exclude three additional medications -- Complera, Prezcobix and Stribild -- that have less costly, and in two cases clinically safer, therapeutic alternatives.

All of our decisions are supported by clinical guidelines and independent, actively practicing physicians and pharmacists. This group of external experts, the Express Scripts P&T Committee, reviews all decisions for clinical appropriateness prior to any financial assessment.

Clinically, it is not in patients’ best interest to switch HIV therapy if they are stable on their current regimen, so these exclusions only apply to people who are new to therapy. People currently using an excluded medication will be grandfathered into coverage without restriction. New-to-therapy patients may be granted a clinical exception if needed.

Our P&T Committee requires preferred alternatives to be therapeutically appropriate for the majority of patients; as such, we expect the number of people who will need a clinical exception to be very low.

We’ve also taken care to ensure any single-tablet regimen (STR) that we have excluded has a single-tablet alternative, as our research has suggested STRs are associated with better adherence and lower costs compared to multi-tablet regimens.

Affordability, care and choice are critical priorities for plan sponsors and their members. Our National Preferred Formulary continues to be a carefully crafted formulary that delivers savings with minimal member impact, leading to more favorable medication adherence and reduced wasteful spending.

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