WASHINGTON, D.C. (May 25, 2022) – A new report from Xcenda finds that pharmacy benefit managers (PBMs) are increasingly restricting patient access to prescription medicines. In 2022, 1,156 medicines were excluded from at least one of the three largest PBMs’ standard commercial insurance formularies, a nearly 1,000% increase in the number of excluded medicines since 2014. Brand medicines without a generic or biosimilar alternative accounted for nearly half (47%) of total formulary exclusions, leaving patients with fewer treatment options.

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. Conflicts of interest can lead PBMs to make decisions that may drive up costs for patients. For example, the three largest PBMs frequently excluded lower list priced insulins from their formularies, instead choosing to cover higher list price versions with large rebates. This can lead to higher out-of-pocket costs for patients with deductibles and coinsurance, who often pay cost sharing amounts tied to the list price of medicines.

“PBMs have earned their reputation as middlemen by finding ways to stand between patients and their medicines,” said Stephen J. Ubl, president and chief executive officer of PhRMA. “These tactics may help increase profits for middlemen, but they can also lead to higher out-of-pocket costs for patients and less 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.”

Key findings from the report include:

Patients with chronic conditions frequently experience access restrictions due to PBM formulary exclusions. 

• For example, medicines to treat multiple sclerosis, mental health disorders, Parkinson’s disease, epilepsy, and other serious complex central nervous system conditions experienced 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.

PBMs increasingly exclude authorized generic and biosimilar insulins with lower list prices while covering higher list priced versions, even though this can lead to higher out-of-pocket costs for patients with coinsurance and deductibles.

• In 2022, for example, two of the three largest PBMs excluded insulin authorized generics, which can have list prices that are half that of the equivalent brand product. Similarly, all three of the nation’s largest PBMs chose to exclude a lower list priced biosimilar insulin in favor of a higher list priced version with a large rebate.

Formulary exclusions can undermine Congressional efforts and existing policies designed to expedite access to safe and effective medicines for patients lacking other treatment options.

• 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.

View the full report here.