2021 Formulary Exclusion Lists: A Review of Express Scripts, CVS Caremark, and OptumRx

It’s that time of year again, PHSL’s annual review of the PBM formulary exclusion list updates!  Express Scripts (ESI), CVS Caremark, and OptumRx have published their formulary exclusion lists for 2021.  Based on PHSL’s calculations, ESI leads the way with 117 new formulary exclusions. CVS Caremark added 62 new exclusions.  OptumRx will exclude an additional 38 drugs.  The new 2021 exclusions, as researched by PHSL, are as follows:

FormularyExclusions

During the review, PHSL made the following observations:

  • OptumRx focused more attention on the respiratory class this year, excluding an additional 9 agents. Examples of excluded agents include ProAir Respiclick, Incruse Ellipta, and Xopenex HFA.
  • ESI seemed to focus on the oncology class for formulary exclusions in 2021, with products such as Avastin, Rituxan, and Herceptin no longer included on the formulary.  For Avastin, ESI prefers the biosimilars (Mvasi and Zirabev).  Similarly, ESI prefers the biosimilar Ruxience, instead of innovator Rituxan and biosimilar Truxima.  ESI also selected two biosimilars (Kanjinti and Trazimera) instead of innovator Herceptin and biosimilars Ogivri and Ontruzant.
  • CVS focused on women’s health, in particular the menopausal symptom category, with seven formulary exclusions.  Examples include Premarin Cream and Estring.
  • Although initially only available as authorized generics, additional generic manufacturers are now producing albuterol sulfate inhalers.  Because of these generic launches, all three PBMs are now excluding brand agents ProAir, Proventil, and Ventolin, and this once brand-competitive space is now genericized.
  • All three major PBMs have chosen to exclude Udenyca (biosimilar to Neulasta) in 2021.  CVS and ESI also included Neulasta as exclusions in 2021.  ESI prefers two biosimilars (Fulphila and Zietenzo), OptumRx prefers brand Neulasta and biosimilar Ziextenzo, and CVS prefers Zienxtenzo as well.  Sandoz’s Ziextenzo is benefiting from these changes, but with the volume of pegfilgrastim billed through the medical benefit, these changes may represent only a fraction of the total market.
  • As mentioned in our 2020 Exclusion List Review, ESI continues to use indication-based management for the “inflammatory conditions” drug class. Reviewing the updates to that category, Cosentyx is no longer a preferred agent for 2021.

Each of the major PBMs has taken a different approach to managing drug spend in 2021, and formulary exclusions continue to play a major role.  PBMs exclude products because of clinical, financial, and humanistic reasons.  They are making value judgments and have decided covering these products is no longer warranted.  This article represents PHSL’s analysis of publicly available information regarding the three PBMs’ formulary exclusion lists for 2021.  Readers are encouraged to assess the lists for themselves.  Links to the exclusion list source information are provided below.

 

Posted January 2021

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