Pharmacy benefit managers continue to push back against rising drug prices and have dramatically upped the number of drugs on formulary exclusion lists during the last two years, according to a new report by the Tufts Center for the Study of Drug Development.
Looking at the two largest PBMs in the United States, the number of drugs they excluded grew approximately 65 percent between 2014 and 2016 with drug manufacturer rebates to PBMs playing a key role in determining what’s shut out, according to the report. The drug manufacturers’ coupons and co-pay offset provisions also play a key role in determining which drugs are sidelined.
"Payers are responding to rising drug costs with new, more restrictive formulary management policies," said Joshua Cohen, associate professor at Tufts CSDD. "With prescription drug spending in the U.S. having grown more than 8.5 percent in 2015, and projected to continue rising, PBMs are likely to expand their exclusion lists."
The rise in exclusions corresponds with a rise in coupon or co-pay offset provisions drug makers have set up to reduce patient out-of-pocket expenses. The study found such provisions jumped more than eightfold between 2009 and 2015. PBMs and payers see these offsets cutting into traditional formulary management tools like tiered cost sharing. Thus, 90 percent of excluded drugs are those that come with coupon provisions.
Drug makers will be increasingly challenged to corroborate the clinical superiority and cost-effectiveness of their products to contest the PBMs’ exclusions.