Skyrocketing Growth in PBM Formulary Exclusions Raises Concerns About Patient Access

Each year, pharmacy benefit managers (PBMs) issue lists of drugs they will exclude from coverage. This practice started in 2011; by 2016, the 3 largest PBMs – CVS Caremark, Express Scripts, and OptumRx – were releasing so-called exclusion lists. In 2019, these 3 PBMs handled 74% of all prescriptions processed in the US, so their negotiating authority is considerable. Formulary exclusions can limit patient and provider choice and may prevent a patient from accessing a particular medicine without paying completely out of pocket or undertaking a burdensome appeals or exceptions process.

The number of drugs excluded by these highly influential 3 PBMs has exploded. In less than 10 years, the practice of formulary exclusions has grown to exclude nearly a thousand prescription medicines across the 3 PBM formularies. To gain a better understanding of the potential implications of formulary exclusions, Xcenda analyzed how these trends have evolved since 2014 and which therapeutic classes have been most commonly subjected to formulary exclusion. We found that from 2014 to 2020, the number of medicines excluded by 1 or more PBM increased by an average of 34% per year, with the exclusions reaching into therapeutic areas once considered untouchable, such as oncology.

Download the white paper below to learn about the proliferation of PBM exclusions and their implications for patient access.