REPORT: The De-List: How Formulary Exclusion Lists Deny Patient Access to Essential Care

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You can find the full report here: The De-List: How Formulary Exclusion Lists Deny Patients Access to Essential Care

 

The nation’s largest pharmacy benefit managers* (PBMs) have nearly tripled the number of treatments on their annual “formulary exclusion lists,” and could be denying coverage to hundreds of thousands of insured Americans each year, according to a new study from the Doctor-Patient Rights Project (DPRP).

The new report, The De-List: How Formulary Exclusion Lists Deny Patients Access to Essential Care, shows that the number of treatments on Express Scripts’ and CVS’s formulary exclusion lists jumped from 132 in 2014 to 344 for 2018, an increase of more than 160 percent.

DPRP’s study also suggests cancer patients forced to switch to generic treatment formulations, and low-income minority patients treating diabetes are particularly impacted by formulary exclusions.

“Formulary exclusion lists can undoubtedly serve as important tools to help manage the skyrocketing cost of patient care,” noted Stacey Worthy, Executive Director of the Alliance for the Adoption of Innovations in Medicine (Aimed Alliance), a founding member of DPRP. But, in some instances, these lists can also cause stable patients to lose access to their medications in the middle of their treatment regimens, resulting in adverse events. Therefore, formulary exclusion lists must be implemented carefully so as not to disrupt care,” Ms. Worthy said.

 DPRP’s study uncovered how formulary exclusion lists impact specific patient groups:

  • CVS’s Exclusion Policy Raises Questions About Generic Cancer Drugs

CVS broke a “gentlemen’s agreement” last year and became the first PBM to place cancer treatments on its formulary exclusion list, opening the flood-gates for other insurers to exclude the medications as well. The PBM claimed that it was only listing cancer drugs where a generic version was available, and that the exclusions only applied to new patients. But DPRP uncovered a number of studies that call into question the effectiveness of generic forms of the cancer drugs the PBMs are excluding.

  • Diabetes Is Consistently the Most Excluded Treatment Category

In the last four years, the number of diabetes-related treatments on the formulary exclusion lists of the nation’s two largest PBMs increased by almost 80 percent and now constitute one-fifth of all formulary exclusions.

DPRP found that diabetes-related medications were the most excluded treatment category, and the only category where the PBMs had consistently increased the number of exclusions every year since they both began issuing formulary exclusion lists.

  • Low-Income and Minority Patients Are Especially Vulnerable to Exclusions

Low-income African American and Hispanic diabetics may be more likely than others to respond to formulary exclusions by skipping doses to make the original prescription last longer or by discontinuing treatment altogether, according to DPRP’s research.

 

Even if only a small percentage of patients respond to formulary exclusions by reducing adherence or discontinuing treatments, DPRP’s study concludes that the resulting medical costs may be greater than what insurance companies save by excluding the treatments in the first place.

The De-List: How Formulary Exclusion Lists Deny Patients Access to Essential Care can be downloaded at www.doctorpatientrightsproject.org.

Other reports available at DPRP’s website include:

Access Denied: How Utilization Management Protocols Can Block Access to Life-Saving Treatments, DPRP’s 2017 report exploring how five specific insurance company cost-saving strategies can block access to vital treatments for many patients when insurance companies pursue them too aggressively.  

Not What the Doctor Ordered: Barriers to Healthcare Access for Patients, DPRP’s report on its 2017 survey of insured Americans about their access to medications, tests, and medical procedures can also be downloaded at the DPRP website.

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The Doctor-Patient Rights Project is a non-profit coalition of doctors, patients, caregivers and advocates fighting to restore the fundamental practice of medicine and ensure doctors, in partnership with their patients, drive patient care decisions. DPRP believes treating practitioners should be the primary voice helping patients determine their best course of treatment, and that third-party payers should partner with physicians to facilitate care and not impose treatment decisions on doctors or patients.

* PBMs are hired by insurance companies to negotiate discounts from drug manufacturers and oversee pharmacy benefits for patients. Express Scripts and CVS are the two largest PBMs and account for more than half of the entire U.S. market share.