Spotlight on Market Access

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.

From more merger and acquisition (M&A) activity due to the incoming administration’s pro-business stance to continued impacts from the Inflation Reduction Act (IRA), 2025 is likely to be a busy year for pharma. Will there be a potential increase in flexibility around planned deals by the Federal Trade Commission (FTC), or will challenges to deals persist? AIS Health spoke with Yana Faykina, director of advisory services at MMIT, and Kristin Pothier, U.S sector leader for life sciences at KPMG, about what the pharma industry may see in 2025. (Editor’s note: These comments have been edited for length and clarity. AIS Health and MMIT are both Norstella companies.) 

Cigna Healthcare, the insurance arm of The Cigna Group, is the fifth-largest health insurer in the U.S., serving nearly 17 million lives nationwide. More than 90% of its members are enrolled in employer-based health plans, though it also ranks ninth in Affordable Care Act exchange enrollment nationwide. While Cigna currently has a robust Medicare Advantage (MA) presence, ranking eighth nationally, the insurer will soon exit the government health insurance business entirely, with plans to sell its MA line to Health Care Service Corp. This deal fueled persistent rumors that Cigna was plotting a merger with MA powerhouse Humana Inc., but the company has consistently quashed any "Cigmana" speculation.

More than two-and-a-half years after it first brought a lawsuit against SaveOnSP, Johnson & Johnson has added two additional divisions of The Cigna Group to the case challenging its copay maximizer program. In a recently unsealed motion, J&J added Express Scripts and Accredo as defendants “to stop a scheme to pilfer tens of millions of dollars from the financial support that JJHCS [Johnson & Johnson Health Care Systems Inc.] provides for patients.”

Traditionally, when a manufacturer provides copay assistance for one of its drugs, that dollar amount would count toward the patient’s deductible and out-of-pocket maximum. But copay maximizer programs will distribute 100% of available manufacturer copay offset funds over 12 months, as opposed to copay accumulators, which apply the maximum manufacturer assistance up front and deplete that contribution before the end of the year. Payments in both approaches do not count toward members’ deductibles and out-of-pocket maximums.