Released on Apr 8, 2021

Patient care issue: Express Scripts stops covering low-volume bowel prep

 

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

Exceptions Process

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:



 


About Gastrointestinal Endoscopy
Gastrointestinal endoscopic procedures allow the gastroenterologist to visually inspect the upper gastrointestinal tract (esophagus, stomach and duodenum) and the lower bowel (colon and rectum) through an endoscope, a thin, flexible device with a lighted end and a powerful lens system. Endoscopy has been a major advance in the treatment of gastrointestinal diseases. For example, the use of endoscopes allows the detection of ulcers, cancers, polyps and sites of internal bleeding. Through endoscopy, tissue samples (biopsies) may be obtained, areas of blockage can be opened and active bleeding can be stopped. Polyps in the colon can be removed, which has been shown to prevent colon cancer.

About the American Society for Gastrointestinal Endoscopy
Since its founding in 1941, the American Society for Gastrointestinal Endoscopy (ASGE) has been dedicated to advancing patient care and digestive health by promoting excellence and innovation in gastrointestinal endoscopy. ASGE, with more than 15,000 members worldwide, promotes the highest standards for endoscopic training and practice, fosters endoscopic research, recognizes distinguished contributions to endoscopy, and is the foremost resource for endoscopic education. Visit www.asge.org and www.screen4coloncancer.org for more information and to find a qualified doctor in your area.

 

American Society for Gastrointestinal Endoscopy
3300 Woodcreek Drive Downers Grove, IL 60515
P (630) 573-0600
F (630) 963-8332
 www.asge.org
 www.screen4coloncancer.org

Media Contact

Andrea Lee
Director of Marketing and Communications
630.570.5603
ALee@asge.org