2025 Formulary Changes: Express Scripts

The following is an analysis of the Express Scripts (ESI) 2025 formulary changes for the National Preferred Formulary (NPF), effective January 1, 2025. PSG’s clinical team evaluated the changes, including an impact analysis based on our book of business dataset, to provide an overview of the most important considerations. In terms of excluded drugs, a total of 21 drugs from 11 therapeutic categories will be excluded from the NPF, and 9 drugs currently excluded or non-preferred will be added back to the formulary. The majority of the excluded drugs (18) are single-source brand products.  Additionally, ESI announced updates to its strategy for inflammatory conditions, which includes the exclusion of brand Humira for new utilizers effective 1/1/2025 and for all utilizers effective 7/1/2025.

Notable Observations

• The quantity and impact of ESI’s 2025 formulary exclusions are less than what was observed in past years. Compared to 2024 changes, the number of specialty drugs impacted is less than half of those excluded in 2024.
• The diabetes and ophthalmic categories presented the largest impact to members.
• ESI’s announcement regarding the exclusion of brand Humira will likely have minimal initial impact as only new users will be affected on 1/1/2025. However, the financial impact of the shift to biosimilars may be more significant after 7/1/2025, when the brand Humira will be excluded for all users.

Some of the more notable drug exclusions are highlighted below.

*Not inclusive of all excluded drugs in the category

Diabetes Category

Formulary changes commonly impact the diabetes category. In both 2023 and 2024, ESI made changes to this category. This will continue as changes effective 1/1/2025 will be made to insulin and sodium glucose co-transporter-2 (SGLT-2) inhibitors.

Insulin

One formulation of a rapid-acting human insulin, Humalog U-100 vial, will be excluded. However, other dosage forms, Humalog Tempo, cartridge, and Kwikpen, will remain preferred. The impact of this exclusion will be minimal as current utilizers of the vial dosage form can continue therapy. Additional rapid-acting insulins, such as insulin lispro, a lower-cost biosimilar, remain preferred on the NPF.   

The long-acting insulin category will also be impacted with the exclusion of Basaglar (insulin glargine).     Two biosimilars, insulin glargine-YFGN and Semglee, as well as other long-acting branded insulins, Tresiba and Toujeo, will be the preferred alternatives. Although these insulins are clinically similar, variations in delivery devices and patient preferences may cause some member disruption.

SGLT-2 Inhibitors

Two SGLT-2 inhibitors, Steglatro (ertugliflozin) and Segluromet (ertugliflozin/metformin), indicated for the treatment of type 2 diabetes, will be excluded effective 1/1/2025. Farxiga and Jardiance will serve as the preferred alternatives to Steglatro, while Synjardy and Xigduo XR will be the alternatives to Segluromet.  Although there are SGLT-2 inhibitors with lower list prices that could be considered preferred alternatives,  Farxiga and Jardiance are preferred due to the clinical advantages they offer with additional FDA-approved indications as well as being more highly utilized. In January 2024, an authorized generic version of Farxiga was launched. However, it does not currently offer a significant cost advantage compared to the brand drug. Other Farxiga generics are expected to launch on or after October 2025 at a discount over brand Farxiga, which could drive some cost savings in this highly utilized category.

Weight Management – Saxenda

 Saxenda (liraglutide), a GLP-1 agonist, will be excluded from the NPF, and Wegovy and Zepbound will be  the preferred alternatives. Saxenda was the first GLP-1 agonist approved for weight loss almost ten years ago.  Compared to Saxenda, the newer, second-generation GLP-1 agonists are more effective, resulting in greater weight loss. They also have fewer instances of side effects and are more conveniently dosed – once weekly versus once daily. The exclusion of Saxenda should have limited member impact as utilization has shifted to the second-generation GLP-1 agonists.

Osteoarthritis – Euflexxa

Euflexxa (sodium hyaluronate) is a viscosupplement indicated for the treatment of osteoarthritis of the knee in patients who have failed to respond to non-pharmacologic therapies or analgesics. When injected into the knee joint, the product functions as a lubricant/shock absorber. Multiple formulations of viscosupplements are currently available, all of which are clinically similar.  However, there are differences in the dosing interval, with some requiring three weekly injections (ie Euflexxa) and others one injection. Euflexxa will be removed from the NPF effective 1/1/2025. Clinically similar products, Monovisc, a single injection product, and Orthovisc, a multi-injection product, are the preferred alternatives. Since these products are administered in the provider’s office and more commonly paid for under the medical benefit, the impact to the pharmacy benefit will likely be minimal. According to PSG’s available 2024 book-of-business data, 98% of claims in this category were processed under the medical benefit.

Ophthalmic – Lumigan, Vyzulta

Two brand eye drops, Lumigan (bimatoprost) and Vyzulta (latanoprostene bunod), indicated for the treatment of glaucoma and ocular hypertension, will be removed from the NPF. Like the diabetes category, these ophthalmic drugs impact a higher number of members. This category includes several generic drugs which will be preferred, including a higher strength Lumigan (bimatoprost 0.03%). From a clinical perspective, these alternatives are appropriate since most patients can be effectively treated with the generic drugs. It’s important to note that while several manufacturers have applied for approval to produce a generic version of Lumigan 0.01%, it is not anticipated to be accessible until 2027.

Tier Formulary Status Change for Specialty Drugs

Two high-cost specialty drugs used to treat rare genetic disorders will become preferred on the NPF effective 1/1/2025.

Haegarda, a prophylactic treatment for Hereditary Angioedema (HAE), will move from a non-preferred status to preferred. HAE is a rare genetic disorder resulting in recurrent and unpredictable attacks of localized or mucosal swelling in various body parts. Due to the variability in patient response, offering an additional formulary option for prophylactic treatment of HAE is appropriate.

Fabrazyme is a drug used to treat Fabry disease, a rare genetic disorder that causes an enzyme deficiency.  The drug will be added to the NPF, which is currently an excluded product.

Multisource Brand Exclusions (MSB)

Three multi-source brand drugs with generic equivalents will be removed from the formulary, and their corresponding generic equivalents will be preferred. Based on PSG’s book of business, the most significantly utilized and potentially cost-saving drug is Forteo, used for treating osteoporosis.

Updates to ESI’s Inflammatory Conditions Strategy

Like other PBMs, ESI continues to refine its anti-inflammatory drug strategy. Although some biosimilars were added to the NPF in 2024, the uptake was relatively low. This is primarily due to brand Humira remaining preferred. That will change in 2025 as brand Humira will be excluded for new utilizers effective 1/1/2025 and for all utilizers effective 7/1/2025. This change should drive utilization to the preferred, lower-cost biosimilars, including Quallent’s approved adalimumab products and two additional biosimilars.

Biosimilars to other anti-inflammatory drugs, including Stelara, are expected to launch early in 2025. ESI plans to co-prefer a biosimilar with Stelara through the first half of 2025. Plans may see some savings in the high-cost category if there is an adequate shift to the lower-cost biosimilar.

ESI continues to refine its NPF by excluding 21 additional drugs effective 1/1/2025 and updating the high-cost anti-inflammatory category by excluding Humira. Unlike other annual formulary exclusions, the member and financial impact of the 1/1/2025 changes is expected to be small as the excluded drugs have lower utilization. Preferring lower-cost generics and biosimilars in several of the affected categories should help plans save on costs.

Need help navigating 2025 formulary changes? PSG has the unbiased clinical and market expertise you need. Contact us today to learn more.