2022 Formulary Exclusions Lists: A Review of Express Scripts, CVS Caremark, and OptumRx

As we prepare for 2023 formulary exclusions to be implemented, we wanted to look back at 2022 formulary exclusions for Express Scripts (ESI), CVS Caremark, and OptumRx. Based on PHSL’s review, ESI led the way with over 108 formulary exclusions. CVS Caremark added 95 new exclusions, while OptumRx only excluded an additional 80 drugs. Although CVS Caremark excluded nearly 100 new drugs, they noted that 99.61% of their clients would not be impacted by any medication changes because of the formulary removals. The 2022 exclusions, as researched by PHSL, are as:

ESI 2023 Exclusions

CVS 2023 Exclusions

Optum 2023 Exclusions

 

During the review, PHSL made the following observations:

  • ESI focused more attention on dermatologic agents and autonomic & central nervous system products. Examples included Tazorac 0.05% Cream, Fabior, and Ultravate for dermatologic agents. Examples of autonomic & central nervous system products included Dhivy, Baclofen solution, and Lybalvi.
  • CVS Caremark’s main focus was on dermatologic agents and pain medications, with 14 exclusions in each category. Examples included ivermectin gel, desonide gel, and for the dermatologic agents. Meloxicam capsules, butalbital-acetaminophen 25-325 mg tablets, and diclofenac potassium 25 mg tablets are some of the pain medications excluded from formulary last
  • OptumRx focused on dermatologic agents and chemotherapy agents. Dermatologic agents excluded by OptumRx and other PBMs included Tazorac 0.05% Cream and Fabior. Inqovi, a chemotherapy agent, was excluded from formulary without a formulary alternative. OptumRx advised patients to consult with their provider about clinically appropriate options.
  • All three PBMs excluded an oral formulation of diclofenac last With both ESI and CVS excluding diclofenac potassium 25 mg tablets and OptumRx excluding diclofenac 35 mg capsules.
  • CVS Caremark greatly restricted coverage of diabetic supplies and needles. Any insulin needle or syringe that was NOT BD Ultra-Fine brand was excluded. Any test strip NOT Accu-Chek or OneTouch brand was excluded. CVS Caremark excluded any glucose monitoring system that was NOT the DEXCOM Continuous Glucose Monitoring System (DEXCOM G6), Omnipod Insulin Infusion Pump, or Omnipod Dash Insulin Infusion Pump.
  • In addition, CVS Caremark no longer covered any brand name prenatal . CVS Caremark included four specific prenatal vitamins on their formulary: Prenatal Tab 27-1mg, Prenatal Tab Plus, Prenatal Vitamin Tab Low Iron, and Tricare Tab Prenatal.
  • It is important to note that CVS Caremark excluded only a specific NDC for albuterol sulfate CFC- free aerosol (NDC:66993-0019-68), manufactured by PRASCO Laboratories. Manufacturers that are covered include: Glaxosmith, Cipla, Hikma, Teva, Sandoz, Civica, Par Pharma, and Padagis.
  • It is important to note that CVS Caremark excluded only a specific NDC for paroxetine HCl ER (NDC:), manufactured by APOTEX. Manufacturers that are covered include: Rhodes Pharma, Kremers Urban, Lupin Pharma, Westminster, and Modavar Pharma.
  • OptumRx still requires prior authorization for Hepatitis C, Multiple Sclerosis, and Immunomodulator treatments. Avsola replaced Simponi Aria and Renflexis as preferred immunomodulators. Kesimpta and dimethyl fumarate DR replaced Tecfidera for multiple sclerosis preferred treatments. There was no change in preferred Hepatitis C medications.
  • As mentioned in our 2021 Exclusion List Review, ESI continues to use indication-based management for the “inflammatory conditions” drug class.

Each of the major PBMs took a different approach to managing drug expenditures in 2022, with formulary exclusions continuing to play a major role. PBMs exclude products because of clinical, financial, and humanistic reasons. Each PBM makes value judgements and determines what coverage is no longer warranted. This article represents PHSL’s analysis of publicly available information regarding the three PBM’s formulary exclusion lists for 2022. Readers are encouraged to assess the lists for themselves, using the exclusion list source information provided in the links below.

Stay tuned for PHSL’s review of the PBM 2023 formulary exclusion lists, coming soon!  How do you expect that the 2023 formulary exclusions will compare with those in 2022?

 

 

Additional Resource:

 

Posted: December 2022

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