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

Objective: We examine whether drugs’ excluded versus recommended status on pharmacy benefit manager exclusion lists corresponds to evidence from costeffectiveness analyses, lack of evidence, or rebates.

Data Sources: To find costeffectiveness data for drugs on 2016 exclusion lists of CVS Caremark and Express Scripts, we searched the Tufts CostEffectiveness Analysis Registry and the peerreviewed literature.

Study Design: For each excluded and recommended drug, we compared the mean costperQALY, and we calculated the difference between the numbers of excluded and recommended drugs for which we could find no costeffectiveness evidence.

Data Collection: As keywords in our searches, we used the brand and generic drug name and “costeffectiveness” and “costperqualityadjusted lifeyear.” Of 240 retrieved studies, 110 were selected for analysis.

Principal Findings: The mean costperQALY for excluded drugs was higher ($51,611) than the costperQALY for recommended drugs ($49,474), but not statistically significant. We could find no costeffectiveness evidence in the Registry or peerreviewed literature for 23 of the excluded drugs, and no evidence for 5 of the recommended drugs.

Conclusions: Costeffectiveness does not correlate with a drug's excluded or recommended status. Lack of costeffectiveness evidence favors a drug's excluded status.

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