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Global Healthy Living Foundation Study Reports Nearly Half of Formulary Exclusions Have Questionable Health and Financial Benefits for Patients | Company


A peer-reviewed article published in Journal of Health Sciences from the Global Healthy Living Foundation evaluating the 2022 national formulary of the second largest PBM in the United States found that nearly half (46%) of their 563 exclusions had questionable clinical or financial benefits for patients, meaning that prescribers are forced to select treatments that may have negative financial or medical consequences for their patients. The study also found that in some cases, the exclusions violate the fundamental “formulary” principle, that low-cost generics, authorized generics, or biosimilars should be preferred over equivalent brand name drugs.

“The original intent of the formularies was to encourage the use of the least expensive drug that was also safe and effective for a particular medical condition. However, consolidations of PBMs and their subsequent purchase by large health insurance companies allow three large companies to collectively process more than 75% of prescriptions and what we have now is a distorted system driven by profits that flow from discounts coordinated in secret negotiations between PBMs, payers and drugmakers,” said the Dr. Robert Popovian, Pharm.D., MS, Director of Science Policy at the Global Healthy Living Foundation, Senior Health Policy Fellow at the Progressive Policy Institute and Visiting Health Policy Fellow at the Pioneer Institute and lead author of the study. of a drug means that the insurer will not cover any part of the cost and the patient will have to cover the full cost, which represents ente an insurmountable financial obstacle for many patients.”

Exclusions based on contracts, not patient outcomes

The study evaluated the 2022 Express Scripts National Preferred Form (ESI) because ESI provides a publicly available National Preferred Form exclusion list each year. For each of the 563 exclusions, the research team assigned the therapy to one of three categories. Equivalent substitution (68.6%) means that a brand name, generic or biosimilar drug is excluded in favor of a preferred brand name, generic or biosimilar drug containing the same active ingredient. A therapeutic substitution (29.8%) excluded a brand-name, biosimilar or generic drug in favor of another brand-name or generic drug not containing the same active ingredient, and a complete exclusion (1.6%) meant that a therapeutic drug was excluded without recommendation. alternative. The study found that all therapeutic substitutions were of questionable medical benefit because the excluded formulation is not the same as the alternatives covered by PBM.

“Patients see no financial benefit when PBMs and insurers make drug purchasing decisions,” said Louis Tharp, executive director, Global Healthy Living Foundation. “Half of the exclusions in the forms are justifiable from a cost-benefit perspective. The other half no. As patient leaders, we must insist on more transparency from pharmaceutical benefit management companies about why they are anti-patient half the time. My prediction is because it makes them more money.

Click on this link to consult “Analysis of exclusions from the drug formulary from the patient’s point of view”.

About the Global Healthy Living Foundation

The Global Healthy Living Foundation is a 501(c)(3) nonprofit organization whose mission is to improve the quality of life for people with chronic diseases (such as arthritis, osteoporosis, migraine, psoriasis, inflammatory bowel disease, and cardiovascular disease) by advocating for better access to health care at the community, state, and federal levels, and amplifying education and awareness efforts through its social media framework. The GHLF is also a strong advocate for vaccines. The Global Healthy Living Foundation is the parent organization of CreakyJoints®, the international digital community for millions of arthritis patients and caregivers worldwide who seek education, support, activism and patient-centered research in English and Spanish via our ArthritisPower ® ( Search Registry. In response to the COVID-19 pandemic, GHLF launched a patient support program, informed by a patient council comprised of people living with a wide range of chronic conditions, which now serves over 46,000 subscribers. Through CreakyJoints, GHLF also hosts PainSpot (, a digital risk assessment tool for musculoskeletal conditions and injuries, eRheum (, for telehealth and virtual care support, and a constantly updated podcast library via the GHLF Podcast Network. Visit for more information.

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SOURCE: Global Foundation for Healthy Living

Copyright BusinessWire 2022.

PUBLISHED: 06/06/2022 09:30/DISC: 06/06/2022 09:32

Copyright BusinessWire 2022.