Leading PBMs Unveil Excluded Drugs

From RADAR on Drug Benefits

Effective Jan. 1, CVS Health Corp. will introduce 23 new exclusions of brand medications from its 2019 Standard Control Formulary and UnitedHealth Group's PBM OptumRx will exclude 36 medications — 33 brands and three generics — from its Premium Formulary. That compares with Express Scripts Holding Co.'s earlier announced exclusion of 48 brand medications in its 2019 National Preferred Formulary.

OptumRx offered a Jan. 1, 2019, pharmacy benefit update in its August newsletter, while CVS gave a list of 2019 standard formulary drug "removals and updates" to consultants. CVS has said it won't officially release its formulary exclusion list until October.

"Clients are asking for it because they need to make plan decisions, and PBMs are saying, 'Here's some; the rest [of the information is coming] later,'" says Michael Hunter, Pharm.D., pharmacy management consultant at Milliman, Inc. This is especially concerning since PBMs tend to have multiple formularies tied to different financial offers that must be weighed by employers and plan clients in their preparations for Jan. 1, he adds.

Experts see an escalating trend in formulary exclusions for 2019: Some specialty drugs are being thrust out of major formularies as an increasingly competitive pharma marketplace begins to offer options, even for some rare diseases.

Broadly speaking, all PBM formularies continue to evolve, says Lynn Nishida, R.Ph., area vice president for pharmacy services at Solid Benefit Guidance. She notes that the three PBMs "are all touching specialty pharmacy and excluding some rare disease items," as well as excluding some expensive generics.

Nishida adds that discounts the PBMs have been able to get from drug manufacturers are likely the main driver of their 2019 formulary additions and enhancements. "These are products at least comparable for efficacy and safety, generally, but excluded last year and brought back — not because of scientific evidence, but likely better contracting. It just creates an on again/off again phenomenon in this market."

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