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- Title
Rising Drug Costs Drives the Growth of Pharmacy Benefit Managers Exclusion Lists: Are Exclusion Decisions Value-Based?
- Authors
Cohen, Joshua P.; Khoury, Christelle El; Milne, Christopher‐Paul; Peters, Sandra M.; Milne, Christopher-Paul
- Abstract
<bold>Objective: </bold>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.<bold>Data Sources: </bold>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.<bold>Study Design: </bold>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.<bold>Data Collection: </bold>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.<bold>Principal Findings: </bold>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.<bold>Conclusions: </bold>Cost-effectiveness does not correlate with a drug's excluded or recommended status. Lack of cost-effectiveness evidence favors a drug's excluded status.
- Subjects
PHARMACY benefit management; DRUG prices; REIMBURSEMENT; COST effectiveness; DRUGS; REBATES; DRUGS &; economics; COMPARATIVE studies; RESEARCH methodology; MEDICAL cooperation; RESEARCH; USER charges; EVALUATION research; QUALITY-adjusted life years
- Publication
Health Services Research, 2018, Vol 53, p2758
- ISSN
0017-9124
- Publication type
journal article
- DOI
10.1111/1475-6773.12781