#TBT: Restrictive Formularies & Potential Pitfalls

As part of our Throwback Thursday blog series, we’re taking a look at a topic that’s currently in the news and tagging it with previous research, videos or commentaries in a relevant way. As the saying goes, “what’s old is new again” – and we hope you enjoy our wonky twist on #TBT.

Express Scripts and CVS Caremark, the two largest pharmacy benefit managers (PBMs), recently released their 2016 formulary exclusion lists detailing which medicines will not be covered by health plans utilizing their services. Each year the lists continue to grow. Express Scripts will not cover almost 20 new prescriptions on its preferred formulary, bringing its total of excluded drugs to 80 compared to 66 in 2015. CVS Caremark’s exclusion list has 124 products compared to 95 in 2015.

In some cases, the exclusions reflect the availability of a generic equivalent; in other cases, the reason for the exclusion is related to the PBM’s business strategy.

However, for people with chronic conditions such as multiple sclerosis and mental illness, restricted access to their current treatment regimens can have severe consequences, such as disease progression, hospitalization or worsened health outcomes and quality of life.

When it comes to health treatments, each person is unique because of a multitude of factors, such as racial and ethnic backgrounds, age, genetics, chronic conditions and comorbidities, disease severity, gender, environment, and even personal preferences. These and other factors make patients different and affect how they may respond to a certain treatment. For these reasons, while the “average patient” may respond best to a particular treatment, some patients may experience little to no benefit from it, so other treatment options may be best for them. These differences in how patients respond to treatments are known as individual treatment effects.

In particular, individual treatment effects should be taken into account for people with depression. A 2001 study, “Formulary Restriction of Selective Serotonin Reuptake Inhibitors (SSRI) for Depression: Potential Pitfalls,” (and our #TBT pick of the week) explored the intended and unintended consequences of having a single or exclusive SSRI on a formulary.

The study found that patients who were forced to switch antidepressants (due to a presumed interchangeability within the class of SSRIs and subsequent formulary restrictions) remain in treatment 50 percent longer and cost approximately 50 percent more to treat. In this case, giving the primary care physician and the patient more treatment options has the potential to reduce overall treatment costs. 

To learn more about individual treatment effects and formulary decision-making, the National Pharmaceutical Council has also conducted research on how and when health care decision-makers should consider individual treatment effects; reasons behind differences in treatment effects; and increasing clarity, consistency, and transparency of how evidence is applied by payers during the formulary decision-making process.