Robert Popovian*, Anne M. Sydor and Peter Pitts
Objective: Pharmacy benefit management companies (PBMs) often determine medication reimbursement with formularies, which were initially intended to ensure use of the least-costly still effective medication. Today, formularies are designed to maximise concessions (ie, rebates and fees) from PBMs through the biopharmaceutical industry. Exclusions may no longer benefit patients by controlling costs, but rather serve to enhance the ability to drive the amount gained through rebate contracting. In this brief report, we evaluate excluded drugs on the only national formulary that is publicly available in the US from the perspective of whether or not the exclusions benefit patients.
Methods: We analysed exclusions of the 2022 national formulary of the second-largest PBM in the US that is publicly available. We categorised substitutions as equivalent (same active agent used) vs. therapeutic (different active agent). We evaluated each exclusion by potential clinical or economic outcomes from a patient perspective.
Results: Close to half (46%) of the 563 exclusions had questionable clinical or financial benefits to patients, requiring prescribers to choose treatments that may have adverse financial or medical outcomes for their patients.
Conclusions: Because patient co-pays and deductibles are based on retail prices, some formulary exclusions force patients to pay substantially more for a preferred drug than an excluded drug or use a medication with questionable medical benefit for their condition. Further research is needed to understand how many patients are affected by such exclusions.
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