Radar on Drug Benefits

When it comes to how the country’s three dominant PBMs cover the blockbuster drug Humira (adalimumab) and its many biosimilars, one year has made a major difference.  

As of 2025, AbbVie’s Humira either “has or will vanish from PBMs’ standard formularies,” Drug Channels CEO Adam Fein, Ph.D., wrote in his annual post analyzing which drugs were excluded on the standard commercial formularies offered by The Cigna Group’s Express Scripts, CVS Health Corp.’s Caremark and UnitedHealth Group’s Optum Rx, as of January 2025. 

One of the most notable drugs missing from the three largest PBMs’ standard commercial formularies this year is Humira (adalimumab), AbbVie’s blockbuster drug for treating autoimmune conditions that has seen significant biosimilar competition in the U.S. since 2023.

Overall, The Cigna Group's Express Scripts removed 21 medications from its 2025 National Preferred Formulary, while CVS Health Corp.’s Caremark and UnitedHealth Group’s Optum Rx cut 16 and 12 drugs from their Standard Control Formulary and Premium Standard Formulary, respectively, according to Pharmaceutical Strategies Group’s analysis.

Despite mostly lukewarm fourth-quarter 2024 results from their parent companies, CVS Health Corp.’s Caremark, The Cigna Group’s Express Scripts and UnitedHealth Group’s Optum Rx showed strong results and optimistic outlooks for 2025. 

The CEOs of those companies also fired back at PBM criticism, stating that PBMs are crucial to negotiating and keeping drug prices low. PBMs have faced pressure from both lawmakers and the public, including administrative complaints and lawsuits aimed at alleged price fixing and claims of contributing to the opioid epidemic. Federal lawmakers have also pushed for legislation to change PBM business practices and increase transparency — and could include PBM reform measures in a budget reconciliation bill as early as March. 

The National Community Pharmacists Association (NCPA) late last month joined in a class-action lawsuit against GoodRx and four major PBMs, alleging the companies are working together to suppress reimbursement to independent pharmacies. Meanwhile, NCPA CEO Douglas Hoey tells AIS Health that even as PBMs such as The Cigna Group’s Express Scripts tout initiatives to help with the plight of independent pharmacies, “PBMs are putting them out of business” with payments that are oftentimes below the cost of operating their pharmacies. 

The NCPA filed its lawsuit on Jan. 22 in the U.S. District Court’s Central District of California Western Division, the same jurisdiction as separate lawsuits filed last fall by Community Care Pharmacy, which is based in Michigan, and Keaveny Drug, a Minnesota-based pharmacy.  

If the new Congress agrees with some Republican lawmakers’ view that the Medicare Part D Premium Stabilization Demonstration is a “taxpayer-funded bailout” for health insurers, it can either defund the program or limit CMS’s authority to create such demonstrations in the first place, pointed out a recent report from the Congressional Research Service (CRS).  

However, one health policy expert says that any action regarding the controversial demonstration is more likely to come from CMS than from Congress.