Summary of the Big 3 PBM 2023 Formulary Changes



Renee Rayburg, RPh
October 11, 2022

Get the Full Analysis of the Big 3 Formulary Changes:

 


 

As we begin the last quarter of 2022, PBMs have announced their 2023 formulary changes and are actively working with payers as they adjust and prepare for these modifications, effective 1/1/2023. The new exclusions represent a relatively small number of changes and member impact this year compared to some previous years.

  • CVS Health has the most specialty drug exclusions at 12, followed by Express Scripts (4) and OptumRx (3). All three PBMs are taking advantage of potential cost savings with the availability of generic Esbriet (pirfenidone) tablets, a drug used to treat idiopathic pulmonary fibrosis (IPF). IPF is a rare progressive condition that affects the lungs. Brand Esbriet is available in tablet and capsule formulations, both of which will be excluded by CVS Health and Express Scripts. Only the brand Esbriet tablets will be excluded by OptumRx, which may impact the full potential of cost savings from the availability of a generic for this high-cost drug.
  • Express Scripts has chosen to cover only Becton Dickinson (BD) brand diabetes pen needles and syringes, representing the largest member impact (82%) of the formulary changes.
  • The exclusion of three asthma steroid inhalants: Arnuity Ellipta, Flovent Diskus, QVAR Redihaler, represent the largest member impact (81%) of CVS Health formulary changes. However, these excluded drugs do not offer any clinical advantages over the preferred alternatives, Flovent HFA and Pulmicort Flexhaler.
  • For OptumRx, the exclusion of brand Combigan, a combination eye drop for the treatment of glaucoma, represents the largest member impact (33.5%) of the formulary changes. However, the preferred alternative is the generic equivalent which should lessen any member disruption.

 


 

Coverage of brand drugs in categories with many generics available continues to have an impact when it comes to formulary changes. CVS Health is removing Asacol HD (used for Crohn’s disease and ulcerative colitis), Adderall XR, and Concerta (both used for ADHD) from its Tier 1 brand over generic strategy where members have been getting these brand drugs for a generic copay. With the exclusion of these three brand drugs, members will be transitioned to their generic equivalents, leading to potential member disruption.

OptumRx is removing several high-cost brand stimulant drugs used to treat ADHD (Adzenys XR-ODT, Cotempla XR-ODT, Quillachew, Quillavant XR, Daytrana) and offering several generic stimulant drugs as preferred alternatives. These high-cost brands offer some unique dosage forms, such as orally disintegrating tablets, extended-release oral suspension, chewables, and patches, but do not seem to offer any additional clinical efficacy over the lower-cost alternatives covered.

As many anticipate the entrance to the market of Humira biosimilars in 2023,  the top drug by cost for almost all payers and used for the treatment of many inflammatory conditions, two of the PBMs are adding back brand specialty drugs in the inflammatory conditions category. OptumRx is moving Enbrel to a tier 2 preferred status stating it will “expand options within the TNF class and add value for plans and members.” CVS Health is adding back Ilumya, used for treating plaque psoriasis. Adding additional brand drugs in an already crowded inflammatory conditions category can take market share away from Humira, which could impact potential cost savings the presence of Humira biosimilars in 2023 is expected to deliver.

With most payers continuing to experience increases in trend and spend year over year, any available cost savings is of interest.   As payers look forward to the 2023 formulary changes, it is important to fully understand the impact to their members. Drug cost management continues to be challenging but optimizing available cost savings strategies is essential for payers.



Renee Rayburg helps lead Artemetrx services in Clinical Consulting with more than 30+ years in pharmacy and medical benefit management to support our health plan sponsors, providers, and patients.  Her thought leadership and passion for specialty pharmacy continues to influence the market, including important changes to specialty vendor clinical management products for the betterment of clients.