Rising Drug Costs Drives the Growth of Pharmacy Benefit Managers Exclusion Lists: Are Exclusion Decisions Value-Based?

OBJECTIVE: We examine whether drugs' excluded versus recommended status on pharmacy benefit manager exclusion lists corresponds to evidence from cost-effectiveness analyses, lack of evidence, or rebates.

DATA SOURCES: To find cost-effectiveness data for drugs on 2016 exclusion lists of CVS Caremark and Express Scripts, we searched the Tufts Cost-Effectiveness Analysis Registry and the peer-reviewed literature.

STUDY DESIGN: For each excluded and recommended drug, we compared the mean cost-per-QALY, and we calculated the difference between the numbers of excluded and recommended drugs for which we could find no cost-effectiveness evidence.

DATA COLLECTION: As keywords in our searches, we used the brand and generic drug name and "cost-effectiveness" and "cost-per-quality-adjusted life-year." Of 240 retrieved studies, 110 were selected for analysis.

PRINCIPAL FINDINGS: The mean cost-per-QALY for excluded drugs was higher ($51,611) than the cost-per-QALY for recommended drugs ($49,474), but not statistically significant. We could find no cost-effectiveness evidence in the Registry or peer-reviewed literature for 23 of the excluded drugs, and no evidence for 5 of the recommended drugs.

CONCLUSIONS: Cost-effectiveness does not correlate with a drug's excluded or recommended status. Lack of cost-effectiveness evidence favors a drug's excluded status.