On December 17, The New York Times published an inflammatory and deeply flawed article that knowingly misleads its readers about the work of pharmacy benefit managers (PBMs). In the article about PBMs and the opioid epidemic, The New York Times allowed itself to be manipulated by plaintiffs’ attorneys into uncritically repeating their allegations as fact and willfully ignoring the basic reality of how PBMs work. The article cherry-picks unrelated facts and unproven statements from over a more than two-decade period, taking them out of context to create an entirely false and misleading narrative.
We repeatedly engaged with the Times reporter in good faith to provide facts and explain how PBMs and drug formularies work. Unfortunately, these facts conflicted with the story the reporter wanted to write, and the desire for sensationalized clicks beat out a desire for the truth. This is profoundly troubling for a media publication that should know better.
The opioid epidemic is a tragedy still ravaging America. The causes of the epidemic are many and complex. However, the Times’ willingness to ignore the facts and falsely impugn Express Scripts and other PBMs is deplorable and demonstrates a preconceived agenda rather than a desire to help readers truly understand the reality of the situation.
Here are the facts:
- PBMs like Express Scripts were not in a position to cause the opioid epidemic.
- Prescription opioids are legal, FDA-approved medications that continue to be required as essential to all drug formularies.
- Rebates are not “secret payments” made in “backrooms” – they are fully transparent to clients, and more than 95% of rebates go to clients.
- Rebates did not drive overprescription by doctors or formulary placement for opioids.
- Nearly 95% of opioids prescribed are generics and do not have rebates.
- The majority of Express Scripts’ clients had tools in place to restrict opioid utilization since at least the early 2000s.
- For more than two decades, Express Scripts has been an acknowledged leader in the fight against prescription opioid abuse and misuse. Claims that Express Scripts launched tools to restrict opioid use only after the crisis reached its peak are demonstrably false.
More context is below:
1. PBMs like Express Scripts were not in a position to cause the opioid epidemic.
Express Scripts PBM does not manufacture, market, distribute, dispense, prescribe, sell, or ever come into possession of prescription opioids. PBMs are outside the closed system established by the Controlled Substances Act (CSA) and regulated by the U.S. Drug Enforcement Agency (DEA) for disseminating prescription opioids and other controlled substances. PBMs do not diagnose or examine patients and do not prescribe medications.
Express Scripts’ role in reviewing these prescriptions is limited to electronically confirming that a patient has a valid prescription and that prescription is covered in accordance with the patient’s health plan.
2. Prescription opioids are legal, FDA-approved medications that continue to be required as essential to all drug formularies.
Standard drug formularies are based on the determinations of independent physicians and pharmacists who are not employed by Express Scripts. Federal laws, including Medicare Part D and the Affordable Care Act, require prescription opioids to be included on formularies for plans governed by those laws. Every formulary Express Scripts is aware of – whether developed by PBMs, plan sponsors, or the government – includes prescription opioids.
The processes Express Scripts uses to develop its standard formularies ensure that clinical considerations – not cost – are paramount.
3. Rebates are not “secret payments” made in “backrooms.”
The article grossly misrepresents what rebates are and their role. Rebates have been used openly by the pharmaceutical industry for decades with nearly all branded medications. These agreements – which are well known to plan sponsors – simply state if a health plan puts a certain medication on its formulary, the manufacturer will pay rebates if the medication is prescribed and purchased by a plan member.
When a rebate is generated, our clients – the health plans of which individuals are members – decide how they want to use the savings. More than 95% of all rebate dollars are passed through to those clients.
4. Rebates did not drive overprescription by doctors or formulary placement for opioids.
Rebates have no influence on prescribing patterns. Rebates do not pass to the physicians who prescribe opioids, and there is no economic incentive for doctors to prescribe one opioid over another.
Express Scripts never requires that rebate-eligible medications be included on clients’ formularies. In fact, 99% of all generic drugs are included on Express Scripts’ standard formularies, and generic drugs are usually not eligible for rebates.
Contrary to the article’s mistaken assertions, rebates do not drive formulary placement of branded opioids, like OxyContin. Generic opioids receive the most preferred placement on the formularies developed by Express Scripts. This is because generic medications are more affordable and reduce overall health care costs for plan sponsors and their members.
5. Nearly 95% of opioids prescribed are generics and do not have rebates.
The article misleads the reader in suggesting that rebates drove formulary placement and decisions about restrictions.
This is belied by the facts: More than 94% of opioid medications prescribed and dispensed since 2006 have been generic medications. Generic opioids do not have rebates.
6. The majority of Express Scripts’ clients had tools in place to restrict opioid utilization since at least the early 2000s.
Since at least the early 2000s, the vast majority of Express Scripts’ clients had management and/or clinical programs in place that restricted the utilization of prescription opioids to only where clinically appropriate, regardless of any impact to rebate value. These programs included prior authorization, step therapy, and quantity limits, as well as concurrent drug utilization review; retrospective drug utilization review; fraud, waste, and abuse detection programs, and enhanced fraud, waste, and abuse detection programs.
7. For more than two decades, Express Scripts has been an acknowledged leader in the fight against prescription opioid abuse and misuse.
Claims that Express Scripts launched tools to restrict opioid use only after the crisis reached its peak are demonstrably false.
For over two decades, Express Scripts has offered its clients various ways to restrict the utilization of prescription opioids to only where clinically appropriate. These offerings have evolved over time as the understanding of prescription opioids has evolved.
For example, starting in the 1990s, Express Scripts offered its clients an Addictive Substance program, which would notify prescribers when patients exhibited potential signs of opioid abuse. In 2002, even before the FDA warned Purdue Pharma about mismarketing the safety profile of OxyContin, Express Scripts began offering its clients a prior authorization policy that would require strict clinical criteria to be met – such as a cancer diagnosis – before OxyContin could be authorized beyond an initial quantity limit. Purdue was livid. This was clearly not an action that Express Scripts would have taken if the article’s fanciful theory that it was colluding with Purdue to promote OxyContin had any basis in reality – which it does not.
In addition to the tools already mentioned, Express Scripts established numerous other programs that addressed the risks posed by prescription opioids. For example, since the 1990s, Express Scripts has offered its clients concurrent drug utilization review (CDUR), which sends dispensing pharmacists real-time alerts of safety concerns with a medication. Alerts for prescription opioids include adverse drug-drug interactions, high dosage, maximum quantity per day, and therapy duplication.
While Express Scripts can and does flag any benefit claim that exceeds plan limits or that triggers CDUR alerts, it is ultimately up to a patient’s doctor and pharmacist to decide what medication is prescribed and dispensed.
