Report finds PBMs are increasingly restricting patient access to medicines

More than 1,150 medicines were excluded from at least one of the three largest PBMs’ standard commercial formularies in 2022, according to a new report from Xcenda. The report is further evidence of how PBMs are making it harder for patients to get the prescription medicines they need.

The three largest PBMs — CVS Caremark, Express Scripts and OptumRx — manage 80% of all prescriptions and own, or are owned by, some of the largest insurers in the country. These large corporations influence which medicines are covered by insurance and how much patients pay out of pocket. And as this new report shows, patients are facing fewer options:

• Of the 1,156 medicines excluded in 2022, almost half were brand medicines without a generic or biosimilar alternative.
  
  
• The three PBMs frequently excluded lower list priced insulins from their formularies, instead choosing to cover higher list price versions with larger rebates.
  
  
• Compared to 2014, almost six times more cardiovascular treatments were excluded from one or more PBM formulary in 2022.

Xcenda finds that these formulary exclusions can undermine patient and provider choice and may prevent a patient from accessing a particular medicine unless they pay completely out of pocket or undertake a burdensome appeals or exceptions process.

The report also found: 

• Medicines to treat multiple sclerosis, mental health disorders, Parkinson’s disease, epilepsy, and other serious complex central nervous system conditions, experienced particularly dramatic growth in exclusions from 2017 to 2022, with the number of medicines excluded by one or more PBM increasing by an average of 51% each year.
  
  
• PBM exclusions of medicines that were approved through one of the four Food and Drug Administration (FDA) expedited review pathways have accelerated rapidly in recent years. In total, 178 unique medicines were excluded from one or more PBM formulary for at least one year between 2014 and 2022.

Health care decisions should be between the patient and the physician, not middlemen. As PhRMA President and CEO Steve Ubl noted:

“PBMs have earned their reputation as middlemen by finding ways to stand between patients and their medicines. These tactics may lead to lower costs for health plans, but they can also lead to higher out-of-pocket costs for patients and restrict access to prescription medicines. We need to make insurance work like it's supposed to and bring more accountability to middlemen who are getting in the way of patients and the lifesaving care they need.”

To read the full report, click here.