The Big Three PBMs’ Formulary Exclusions Continue to Grow in 2023

Feb 16
Feb 16, 2023

Cigna Corp.-owned Express Scripts removed 43 medications from its 2023 National Preferred Formulary, while the other two major PBMs — CVS Health Corp.’s Caremark and UnitedHealth Group’s Optum Rx — cut 23 and 19 drugs from their formularies in 2023, respectively. Since 2014, the three PBMs have dramatically increased the number of excluded drugs, but the growth rate of exclusions has slowed for the second year in a row.

For 2023, CVS Caremark has the most specialty drug exclusions at 12, compared with four by Express Scripts and three by Optum Rx. The exclusions of three asthma steroid inhalants — GlaxoSmithKline’s Arnuity Ellipta (fluticasone furoate) and Flovent Diskus (fluticasone propionate), and Teva’s QVAR RediHaler (beclomethasone dipropionate) — may lead to potential member disruption. The PBM also replaced several branded products with their newly approved generics. Both the brand tablet and capsule formulations of Genentech’s Esbriet (pirfenidone), a specialty drug to treat idiopathic pulmonary fibrosis, will be excluded from the formulary in 2023, as its generic version was launched in May 2022. Another drug removed in favor of a generic is Takeda’s Velcade (bortezomib), a treatment for multiple myeloma and mantle cell lymphoma.

Meanwhile, Caremark added 13 drugs to its standard formulary, effective Jan. 1, 2023. Approved in 2021, Leo Pharma’s Adbry (tralokinumab-ldrm) is a biologic to treat patients with atopic dermatitis and is the only therapy that targets the interleukin-13 cytokine. In addition, Amgen and Novartis’ Aimovig (erenumab-aooe), a calcitonin gene-related peptide antagonist for migraine prevention, will expand the category as two other injectable CGRP antagonists are currently on the formulary.

Graphics below list notable medications that were excluded or added by CVS Caremark due to 2023 formulary changes and their market access among commercial formularies under the pharmacy benefit, as of December 2022 and February 2023.

Express Scripts added 43 new medication exclusions in 2023, four of which are specialty drugs. Like Caremark, Express Scripts also excluded Esbriet in favor of Sandoz’s generic pirfenidone and Boehringer-Ingelheim’s OFEV (nintedanib). In addition, several specialty drugs — such as Samsca (tolvaptan), Thiola (tiopronin) and Sabril (vigabatrin) — are now excluded, with their lower-cost generic equivalents listed as preferred alternatives.

Optum Rx cut 19 drugs from its standard formulary in 2023, excluding several brand medications in favor of cost-saving generics. Some of the brand medications were higher-cost brand stimulants to treat attention deficit hyperactivity disorder, including Adzenys XR-ODT (amphetamine) and Daytrana (methylphenidate).

According to a Xcenda white paper, 1,156 unique prescription medicines were excluded from the standard formularies of at least one of the three major PBMs in 2022, a 961% increase from 2014. Drugs for autonomic and central nervous system disorders, diabetes and dermatological conditions were most frequently affected by formulary exclusions. In addition, an increasing number of cancer medications and supportive therapies were added to the exclusion lists between 2014 and 2022.

Since the first biosimilar launched in 2015, biosimilar adoption remains challenging in the U.S. As of April 2022, there were 21 biosimilars on the market, yet Xcenda’s analysis shows that in total, 14 biosimilars have been excluded by at least one or more PBMs for at least one year.

NOTES: Under the pharmacy benefit, CVS Health Corp.’s Aetna and its Caremark PBM cover 28.9 million lives under commercial formularies; Cigna Corp. and Express Scripts cover 32.1 million lives; UnitedHealthcare and Optum Rx cover 22.9 million lives.

SOURCES: “Formulary Drug Removals,” CVS Health. “2023 National Preferred Formulary Exclusions,” Express Scripts. “Jan. 1, 2023 Premium Formulary Exclusions,” Optum Rx. “Skyrocketing Growth in PBM Formulary Exclusions Continues to Raise Concerns About Patient Access,” AmerisourceBergen Xcenda. Managed Markets Insight & Technology, LLC database as of December 2022 and February 2023.

This infographic was reprinted from AIS Health’s biweekly publication RADAR on Drug Benefits.
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Jinghong Chen

Jinghong has been producing infographics and data stories on employer-sponsored insurance, public health insurance programs and prescription drug coverage for AIS Health’s Health Plan Weekly and Radar on Drug Benefits since 2018. She also manages AIS Health’s annual executive compensation database for top insurers and Blue Cross and Blue Shield affiliates. Before joining AIS Health, she interned at WBEZ, Al Jazeera English and The New York Times Chinese. She graduated from Missouri School of Journalism with a focus on data journalism and international reporting.