PBMs now target both traditional and specialty products for formulary exclusion.
Thus, a drug’s appearance on an exclusion list does not guarantee that all patients will lose access. (See Tales of the Unsurprised: Brand-Name Drug Prices Fell for the Fourth Consecutive Year.) They can also affect a patient’s out-of-pocket costs and access to a particular therapy.įormulary exclusions block access to specific products on a PBM’s recommended national formulary.
Exclusions are one of the key factors behind the large gap between list and net prices for brand-name drugs. The prospect of exclusion leads manufacturers to offer deeper rebates to avoid being cut from the formulary. Let me know what you think by commenting below or on social media.įormulary exclusions have emerged as a powerful tool for PBMs to gain additional negotiating leverage against manufacturers. I also offer some thoughts on non-medical switching and what we still don’t know about how exclusions affect patients. Growth in the number of excluded drugs slowed, due partly to the fact that so many drugs have already been dropped from PBMs’ formularies.īelow, I highlight five observations about this year’s lists, including unexplainable differences in how PBMs handle specialty drugs, biosimilars, and insulin. For 2022, the three largest pharmacy benefit managers (PBMs)-Caremark (CVS Health), Express Scripts (Cigna), and OptumRx (United Health Group)- increased the number of drugs they excluded from their standard formularies.Įach exclusion list contains 400 to 500 products.
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