Prescription Plan Exclusion Lists Grow at Patients’ Expense

Benefit managers should recognize their responsibility in improving public health

More patients will lose access to the treatments prescribed by their doctors, as one of the country’s largest pharmacy benefit managers refuses to cover a growing number of medications in its prescription plans.

Last month, CVS published its 2017 formulary exclusion list, which included 154 medicines, up 24 percent from last year. The list includes therapies used to treat a variety of serious diseases such as cancer, diabetes and hepatitis C.

Formulary Exclusion Lists Continue to Grow

While CVS Health claims the list is essential to containing costs for clients and providing members with affordable medications, some health care experts see it as nothing more than a move to maximize profits at the expense of patients.

Peter Pitts, president and co-founder of the Center for Medicine in the Public Interest, believes that pharmacy benefit managers are using exclusions lists just to maximize their profits.

Peter Pitts, president and co-founder of the Center for Medicine in the Public Interest, believes that pharmacy benefit managers are using exclusions lists just to maximize their profits.

“Many therapies provide substantial value over the long term, but pharmacy benefit managers like CVS Health don’t recognize that value,” said Peter Pitts, president and co-founder of the Center for Medicine in the Public Interest and former Food and Drug Administration associate commissioner for external relations. “They are prioritizing short-term gains and ignoring their greater social responsibility for improving public health.”

Exclusion lists undermine doctors’ ability to make the best choices for their patients, and patient care and outcomes could suffer as a result.

Pharmacy benefits managers seem to be operating under a “one-size-fits-all” approach; for multiple therapies that performed similarly in clinical trials, they may approve only one. But clinical trials look at averages – they don’t tell us about individuals. So a medicine that works well for one person might not work well for another with the same condition, who instead responds better to a different therapy. Meaning excluding options only hurts patients. In fact, studies have found that access to multiple treatment options for blood cancers improves patient health and lowers total costs.

There should be no exclusion lists. They don’t help patients or the health care system.

“Exclusion lists are relics of a 20th-century approach to medicine,” said Pitts. “If they really want to be innovative, they could start using their member data and working with doctors to help guide treatment decisions. That would be a real benefit to their clients and members—not just to the company’s stock price.” 

Health care stakeholders of all sorts should be focused on improving patient outcomes, according to Pitts. Health insurers are already moving towards paying health providers based on performance to provide more effective and efficient care. If we held pharmacy benefit managers to the same standard, Pitts argues, they wouldn’t create exclusion lists, since medications help to improve health and reduce overall health spending.

Prescription Plans Exclusion Lists: Healthcare Political Cartoon

Absent changes in these policies, the outlook doesn’t look promising for patients. “As we develop more effective treatments and cures, pharmacy benefits managers are going to continue manipulating their formularies,” Pitts predicted. “At the end of the day, there should be no exclusion lists. They don’t help patients or the health care system.”