Health Insurance PBM Pharmaceuticals

Are PBM exclusion lists value-based?

Value-based insurance design (VBID) is a simple concept.  In short, interventions that provide high-value should be covered with little cost sharing; treatments with low-value should be covered with higher rates of cost sharing or in some cases perhaps not even covered at all.

A paper by Cohen et al. (2017) aims to see how far we have come on VBID. Their study asks a more specific question of whether drugsexcluded versus recommended status on pharmacy benefit manager (PBM) exclusion lists corresponds to evidence from cost-effectiveness analyses, lack of evidence, or rebates.  The authors use formulary data from Express Scripts and CVS Caremark.  In particular they examine these two PBM’s use of exclusion lists, which are lists of pharmaceuticals that are excluded from coverage, but are combined with other drugs within the same therapeutic class that the PBM recommends.

In 2016, Express Scripts placed 87 products on its exclusion list, while CVS Caremark put 124 drugs on its exclusion list. This represents a 65 percent increase since 2014. The lists for 2017 indicate CVS has increased the number of excluded products to 154, while Express Scripts have increased its number to 85 (Toich 2017).

The authors aim to examine whether treatments included on the exclusion list had lower estimated coste effectiveness than treatments the were covered (i.e., not on the exclusion list).  The study measures treatment cost effectiveness using data from the Tufts University Cost-Effectiveness Analysis Registry (CEAR).

Using this approach, they find the following:

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.


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