Exclusion Lists Leave Rx’s Off, Patients Behind

July 13, 2022

Evidence continues to mount that exclusion lists – lists of prescription drugs that payers refuse to cover – have less to do with patients and more to do with profits.

More than 1,100 Medications Excluded

It’s a problem that’s been growing for over a decade. Since 2012, the number of excluded medications has increased from fewer than 50 to more than 400 for some pharmacy benefit managers.

The three largest PBMs – CVS Caremark, Express Scripts and OptumRx – had a total of 1,156 unique medications on their formulary exclusion lists in 2022. That’s a 29% jump from the 899 unique medications that were excluded in 2021. And the effect on patients is real.

“Nearly one in three insured Americans who take prescription medicines report the medicine their physician prescribed has been excluded from their insurers’ list of approved medicines,” according to a recent patient experience survey.

Maximizing Profits

Even more troubling than the growing number of exclusions is their increasingly tenuous connection to patient interests.

Pharmacy benefit managers and their clients – health insurers and employers – could return to the original function of exclusion lists: to ensure the “use of the least-costly still effective medication.” That’s why, for years, exclusion lists often included only medications that had a generic alternative or medications for which there were many therapies that were shown to achieve similar clinical outcomes.

But in practice, the lists have become a tool maximizing rebates from drug manufacturers – savings that pharmacy benefit managers are allowed to pocket instead of pass along to patients.

Forcing Patients to Switch

Meanwhile, patients’ best interests are really what’s being excluded.

With more frequency, patients are being forced to switch medications for non-medical reasons, from therapies that are working to alternatives that might not.

Once patients find a medication that works for them, they shouldn’t be forced to change to another one because it’s more profitable for their payer. Non-medical switching can cause burdensome, even dangerous symptoms to re-emerge. It can also be attributable to higher downstream medical costs.

Federal Inquiry

The use of exclusion lists and their surrounding policies is yet another area being reviewed in the Federal Trade Commission’s inquiry of pharmacy benefit managers. The federal probe is also looking into the prevalence of prior authorization, methods to steer patients towards PBM-owned pharmacies and the impact of rebates on patient drug costs, among other topics.

Collectively, these areas have led to dangerous and costly consequences for patients. But, depending on the outcome of the federal investigation, relief may be on the way.

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