Issue Brief: Assessing the impact of formulary exclusion on healthcare costs and outcomes for patients on therapy for certain chronic conditions
By Xcenda
Delaying, changing, or stopping therapy for a medicine due to a formulary exclusion can impact a patient’s health. To quantify the effect of a formulary exclusion, Xcenda evaluated the impact on adverse events and out-of-pocket (OOP) costs for patients who were previously stable on therapy but whose plan stopped coverage due to a formulary exclusion by their pharmacy benefit manager (PBM).
Xcenda analyzed claims for 2 therapeutic areas (cardiovascular therapy and gastrointestinal therapy) as case studies to compare the change in a patient’s health before and after the PBM implemented the formulary exclusion. The results showed that outpatient ED visits for gastrointestinal patients increased by 42%, on average, during the 6 months prior and the 6 months post-formulary exclusion for patients overall. Among patients who were adherent to the gastrointestinal therapy during the 6-months before and 6-months after the formulary exclusion, per-member per-month (PMPM) OOP costs for the therapy rose 12% after the exclusion.
The brief spotlights the negative impact formulary exclusion has on patients, and shows that PBMs have cause to reconsider their formulary exclusion methodology to ensure health outcomes are prioritized, and patients previously stable on therapy can remain on therapy. Download now to learn more.
