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

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Health Services Research

Published online on


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.