Express Scripts Excludes Zohydro from Coverage

Express Scripts Excludes Zohydro from Coverage

Express Scripts, the nation’s largest national Pharmacy Benefit Management Service (PBMS), has dropped Zohydro ER from its 2015 formulary of covered medications. Insured patients whose prescriptions benefits are managed by Express Scripts will pay full price at the pharmacy counter for Zohydro beginning January 1, 2015.

Many health insurance organizations use PBMS to manage pharmacy benefits and costs for their members. PBMS are third party entities that have become a part of the confusing American medical insurance system in recent years. They are responsible for processing and paying prescription claims.

53134b4607be0.preview-300Over 200 million Americans now receive their prescription insurance benefits through PBMS, which use an economy of size in negotiating prices and securing rebates from pharmaceutical companies and large pharmacy chains.

Many people don’t realize there’s a third party involved, until a prescription is denied by the PBMS, leaving the insured person to wonder: “Who are they to deny the medication my doctor ordered?”

A major function of PBMS is to develop formularies, which are the lists of covered medications a patient may receive. These formularies are developed by several panels of experts hired by the PBMS. These panel members come from the fields of medicine, pharmacy, and the pharmaceutical industry.

Express Scripts public communications claim that their formularies “provide affordable access to clinically sound, high-quality pharmaceutical products.” The company says that “clinical appropriateness of the drug, not cost, is Express Scripts’ foremost consideration,” and that “the prescribing physician always makes the final decision regarding an individual patient’s drug therapy.”

Many states are demanding more transparency and fiduciary disclosure to regulate the PBMS industry, requiring it to act in the best interest of health consumers. PBMS, through their representative trade organization, Pharmaceutical Care Management Association, oppose these disclosures for a variety of business reasons, claiming their effect on competition would cause a rise in prices to drug consumers.

Express Scripts is the organization formerly known as Medco Health Solutons. In 2004, Medco Health Solutions agreed to a $29.3 million settlement agreement with 20 states for allegations that the company violated consumer protection and mail fraud laws.

Zohydro ER is the first long acting formulation of the most widely prescribed opioid analgesic, hydrocodone. Manufactured by Zogenix (NASDAQ: ZGNX), Zohydro was approved for use in the treatment of chronic pain in 2013 in a controversial decision by the FDA. Although experts from field of addiction medicine and anti-diversion proponents predicted widespread abuse of this new medication, to date there have been no reported cases of overdoses or diversion of Zohydro ER.

Authored by: Kurt W.G. Matthies

There are 2 comments for this article
  1. Mike C at 3:56 am

    I deal with a Express Scripts daily. Not only do they control what meds you can take, they also control which pharmacy you can use for any non-schedule drug. They will force their “customers” to use only their mail in pharmacy for most recurring medications, or the patient pays full price. Express Scripts claim it’s the provider (employer) who makes it this way, but the provider of the insurance says the opposite. So if your doctor does not want you to have x-number of pills on hand because they are likely to make a change, your out of luck with Express Scripts. It’s 90 day supply or nothing! My prescribing doctor doesn’t prescribe more than 30 days for certain drugs, but ES says they don’t care! What happened to patient’s rights and the freedom to choose our medical providers?

  2. Johnna Stahl at 9:04 pm

    On 7/8/14, as reported by wcvb dot com in Boston:

    Massachusetts must temporarily suspend one of its key restrictions on Zohydro, a powerful new prescription painkiller, pending the outcome of a lawsuit challenging their constitutionality, a federal judge ruled on Tuesday.

    U.S. District Court Judge Rya Zobel ordered the state to stop requiring doctors and other prescribers to issue a so-called “letter of medical necessity” stating that “other pain management treatments have failed” before prescribing the hydrocodone-based drug.

    But, on 8/1/14, Reuters reported:

    “Express Scripts Holding Co, the largest U.S. pharmacy benefit manager, on Friday said it will remove 25 products from its 2015 list of preferred drugs…Other drugs excluded next year are a testosterone gel and extended release Zohydro.”

    So, it looks like it doesn’t matter what our courts decide, the drug has been removed from the all-important formulary… Express Scripts has succeeded in bypassing our court system.

    Buh-bye, Zohydro — only patients who have doctors willing to take the extra time to fight with Express Scripts will have access. (Of course, that will increase the total cost of access even more.)

    I was trying to find out what the big health care groups like Kaiser were doing about Zohydro, and I read a post from 2012 indicating that Kaiser had a new policy — it will no longer treat chronic pain with opioids. Patients said that instead of continuing with pain meds, they are being referred to rehabs in psychiatric hospitals. Is this true, and are other health care systems doing the same?