Effective April 1, 2021, Express Scripts (ESI) no longer covers low-volume bowel preparations in its National Preferred Formulary, affecting 75 million Americans.
ACG, AGA, and ASGE have been in dialogue with Express Scripts for months to fight this change, which diminishes the value of physician decision making and patient choice. We have had meetings with ESI and sent letters sharing data supporting that low-volume preparations are safe, effective and better tolerated than four-liter preparations.
Now we need to hear from you.
Please let us know if your practice is experiences roadblocks to obtaining exceptions for your patients by submitting feedback, which will help guide our societies as we continue toengagewith ESI and other pharmacy benefit management companies, as well as insurers.
GI societies request automated exemptions for certain patients
We are waiting for ESI to respond to our request that they automatically approve exemptions for the following types of patients:
1. Patients with heart failure (specifically with reduced ejection fraction)
2. Patients > 65
3. Patients with gastroparesis
4. Patients with history of gastric resection on restriction including bariatric surgery
5. Patients with a documented history of chronic nausea
Express Scripts has outlined the following exceptions process to its new coverage policy.
Whenever a product is not covered on the formulary, the dispensing pharmacy will receive a message that generally states the following: ‘Drug Not Covered. If an exception is needed, call xxx.xxx.xxxx.’ The prescriber will call that number or the number of the patient’s pharmacy insurance card, request a formulary exception, and answer between 2-5 questions.
While the criteria vary a little bit from one product to another, below are the formulary exception criteria for non-preferred preps:
1. Approve if the patient has tried one other bowel evacuant product (e.g., peg-electrolyte solution, Colyte, GaviLyte, Golytely, Nulytely, TriLyte).
2. If, per the prescriber, the patient requires a low volume bowel preparation, approve if the patient meets one of the following criteria (a, b, c, or d):
a. Patient has tried PEG3350 powder packet (Moviprep, generics).If PEG3350 powder packet (Moviprep, generics) are non-formulary, approve; OR
b. If PEG3350 powder packet (generic of Moviprep) is unavailable; OR
c. Patients with phenylketonuria; OR
d. Patients with glucose-6-phosphate dehydrogenase deficiency.
Thank you for your time. Please contact your GI Society with any questions: