Skyrocketing growth in PBM formulary exclusions continues to raise concerns about patient access

Each year, pharmacy benefit managers (PBMs) issue lists of drugs they will exclude from coverage in the coming year. This practice started in 2011; by 2016, the 3 largest PBMs – CVS Caremark, Express Scripts, and OptumRx – were releasing so-called exclusion lists. In 2021, these 3 PBMs handled 80% of all prescriptions in the US, so their negotiating power 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.

In 2020, Xcenda evaluated the formulary exclusion lists of the 3 PBMs and found that the their standard formularies excluded almost 850 unique prescription drugs that year. Since then, the pace of formulary exclusions has continued at an astonishing rate. As of 2022, the 3 largest PBMs placed a total of 1,156 unique medicines on their standard formulary-exclusion lists. In addition to analyzing which therapeutic classes have been most commonly subjected to formulary exclusion, this update focuses on how the practice has affected treatments for oncology and hepatitis, biosimilars, insulins, single-source drugs, and drugs approved under the Food and Drug Administration’s (FDA) expedited pathways.

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