PBMs are increasingly restricting patient access to medicines, report finds

26 May 2022

More than 1,150 medicines were excluded from at least one of the three largest US pharmacy benefit managers’ (PBMs) standard commercial formularies in 2022, according to a new report from Xcenda. The report is further evidence of how PBMs are making it harder for patients to get the prescription medicines they need, according to trade group Pharmaceutical Research and Manufacturers of America (PhRMA).

The three largest PBMs - CVS Caremark, Express Scripts and OptumRx - manage 80% of all prescriptions and own, or are owned by, some of the largest insurers in the country. These large corporations influence which medicines are covered by insurance and how much patients pay out of pocket. And as this new report shows, patients are facing fewer options:

Of the 1,156 medicines excluded in 2022, almost half were brand medicines without a generic or biosimilar alternative.
The three PBMs frequently excluded lower list priced insulins from their formularies, instead choosing to cover higher list price versions with larger rebates.
Compared to 2014, almost six times more cardiovascular treatments were excluded from one or more PBM formulary in 2022.

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