Top PBMs increase number of formulary exclusions in 2021

The number of formulary exclusions from the nation’s three largest pharmacy benefits managers — Caremark (CVS Health), Express Scripts (Cigna), and OptumRx (United Health Group)—increased significantly in 2021, according to a new analysis.

Many exclusions are brand name treatments with generic equivalents but the PBMs are also leaving off more specialty meds, according to the Philadelphia-based Adam J. Fein, the drug pricing expert.

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“The practice of formulary exclusion began in 2014. Since then, the number of products excluded from the national preferred formularies of the three largest PBMs has grown dramatically,” wrote Fein, Ph.D., whose Drug Channels website is widely read in the industry. “The growth in excluded products shows how competitive many specialty therapy categories have become — and the undisclosed but presumably significant rebates generated by these products.”

CVS Caremark removed 57 drugs and added 6 drugs back in its 2021 standard formulary, according to Fein. Express Scripts expanded it exclusion list by 70 medications. OptumRx excluded 27 more medication in its 2021 standard formulary; by Fein’s tally, that OptumRx’s total exclusion now has 476 products on it.

Express Scripts excluded some major medications in its 2021 standard formulary, including the psoriasis drug secukinumab (Cosentyx, Novartis), the cancer medication Calquence (AstraZeneca), and the PCSK9 inhibitor Praluent (Regeneron, Sanofi).

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Among the notable exclusions in CVS Caremark’s 2021 standard formulary are: the antidepression blockbuster paroxetine hydrochloride (Paxil, GlaxoSmithKline), pegfilgrastim (Neulasta, Amgen), and the otic anti-inflammatories/anti-infectives ciproflaxin hydrochloride (Cipro HC, Bayer) and (Ciprodex, Novartis).

OptumRx/ United Health excluded the blockbuster insulin Lantus (Sanofi) and anti-infection drug Neupogen (Amgen) in favor of the drugs’ biosimilars. The PBM also excluded leukemia treatment Gleevec (Novartis).

The PBMs differ in how they handle formulary exclusions and additions, Drug Channels noted. Express Scripts and OptumRx both excluded Cosentyx, but CVS Caremark did not. CVS Caremark excluded etanercept (Enbrel, Wyeth) for psoriasis only, but Express Scripts and OptumRx did not.

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