Formulary exclusion lists make it harder for patients to get prescriptions

In 2017, one in four insured Americans were denied access to treatment for a chronic illness, according to DPRP. (Image: DPRP)

CLEVELAND, Ohio - Getting a prescription these days requires more than just a visit to your doctor.

Insurance companies use formulary exclusion lists to dictate which prescriptions are covered, and the number of medications on those lists continues to grow as prescription insurers try to cut costs.

As a result, patients are being denied prescriptions or being forced to switch to new treatment plans, despite what their doctor initially recommends.

"Many people think that as long as they have health insurance, their prescribed medication or treatment will be covered. They are not aware of formulary exclusion lists until their insurer notifies them that a treatment is no longer covered or they receive a shock when they see the medication's price at the pharmacy," said Stacey Worthy, a founding member the Doctor-Patient Rights Project (DPRP), a coalition of doctors, patients, caregivers, companies and advocates, and executive director of Aimed Alliance, a nonprofit promoting the improvement of healthcare.

Since 2014, two of the largest prescription insurers in the country, Express Scripts and CVS Health (Caremark), increased the number of drugs on their formulary exclusion lists 161 percent, from 132 to 344, according to a new study, "The De-List: How Formulary Exclusion Lists Deny Patients Access to Essential Care," by DPRP.

Express Scripts and CVS Health, which handle more than half of all prescription claims in the U.S., are what are known as pharmacy benefit managers (PBMs) and act as middlemen between drug manufacturers and insurance companies.

CVS Health estimates its formulary exclusion strategy from 2012 through 2018 will save $13.4 billion in drug costs. Likewise, Express Scripts expects to cut costs $7.4 billion from 2014 through 2018.

The excluded medications are often times ones that aren't prescribed very often or that have generic alternatives, but recently a couple of specialty drugs, including some for Hepatitis C, are also popping up on these lists.

In 2017, one in four insured Americans were denied access to treatment for a chronic illness, 37 percent of whom were denied because of a formulary exclusion, according to a survey of 1,500 people Schoen Consulting completed for DPRP. Others were denied for a number of reasons, such as the treatment was deemed medically unnecessary or prior authorization was required.

June Zenner-Marion, a local Cleveland Clinic patient with chronic arthritis, had to share a Celebrex prescription with her husband, who was on the same medication, because of delays in authorization.

After requesting a refill of the generic form of Celebrex, she found out the drug now required prior authorization, a process that differs by insurance company and means physicians need to submit requests to get medications approved. Prior authorizations then can be denied by insurance companies, requiring doctors to either file appeals if they want their patients to get the medication or prescribe a different drug that is included on their formulary.

Zenner-Marion has insurance coverage through Anthem Blue Cross Blue Shield, which recently announced it planned it launch its own PBM with CVS Health starting in 2020.

"I do not want opiods; I just want relief," Zenner-Marion said.

If you purchase a product or register for an account through a link on our site, we may receive compensation. By using this site, you consent to our User Agreement and agree that your clicks, interactions, and personal information may be collected, recorded, and/or stored by us and social media and other third-party partners in accordance with our Privacy Policy.