Drugs Left Off PBM Lists Can Lead to Worse Patient Outcomes, Higher Costs

HealthCare Brew
Maia Anderson

Pharmacy benefit managers (PBMs) are leaving more drugs off their formularies, which may prompt doctors to prescribe drugs that aren’t as effective or are more costly.

PBMs are companies that work on behalf of insurers and negotiate with drug manufacturers to create formularies, which are lists of drugs the insurers cover. PBMs also create lists of the drugs they exclude from their formularies, and these drugs therefore don’t get covered.

When drugs are left off formularies, patients have to pay more out of pocket to get the drugs they need. For those who can’t afford it, that can mean worse health outcomes and higher overall healthcare costs.

Exclusion lists have gotten longer every year, and these most often affect drugs for chronic illnesses, according to research from Xcenda, a pharmaceutical consulting firm owned by drug wholesaler AmerisourceBergen (which is expected to rebrand as Cencora in 2023).

“Who bears the consequences is really the prescriber, from a liability standpoint and also from a patient care standpoint. The patient can potentially have poor outcomes,” Robert Popovian, chief science policy officer at the Global Healthy Living Foundation, a nonprofit that advocates for increased access to healthcare services for people with chronic illnesses, told Healthcare Brew.

Back in the day

Formularies were initially created to make sure doctors prescribed patients the least expensive drugs that were still effective, according to research that Popovian conducted with the foundation in 2022.

PBMs began making formulary exclusion lists in 2011, according to Xcenda. CVS Caremark was the first to do so for the 2012 plan year, followed by Express Scripts in 2014 and Optum Rx in 2016.

Since then, the number of drugs left off formularies has risen sharply. In 2014, at least one of the top three PBMs excluded a total of 109 drugs, and in 2022, that number rose to 1,156, according to Xcenda’s research. In 2023, the top three PBMs each excluded about 600 drugs from their formularies, according to Drug Channels data.

READ MORE