Insights into the
2021 PBM Formulary Changes



Renee Rayburg, RPh, Vice President of Specialty Clinical Consulting
October 14, 2020

 

Thinking back to one year ago, when writing this commentary on the upcoming 2020 formulary changes, no one could have foreseen the challenges and difficulties 2020 has presented. The 2021 formulary changes proposed by the “Big Three” PBMs (Express Scripts, CVS, and OptumRx) may be even more meaningful to plan sponsors as they relate to cost containment.

Drug Exclusions

Express Scripts leads the pack with the most drug exclusions at 70. While OptumRx is putting forward the least number of exclusions at 50.

Member Impact

When looking across our book of business, CVS’s changes are showing the lowest member impact at 1.4 percent, while cost impact across the Big Three ranges from 2 to 3.1 percent.

Want to find out how these changes may impact you? Contact PSG today to get the formulary strategy and support you need for an ever-evolving market.

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All three have made changes in diabetes, specialty drugs, generics, and biosimilars. The most notable highlights are discussed below.

Diabetes

  • Diabetes is a top category of spend for most plan sponsors, and it will see changes from all three in 2021.
  • Express Scripts is narrowing coverage of its type 2 diabetes drug classes when Januvia and its combination products will be the only DPP4 inhibitor drugs covered.
  • CVS and OptumRx are making changes to their preferred test strips.
    • CVS is removing Accu-Chek® and will add back OneTouch®  test strips, which were removed just two  years ago.  Members currently utilizing Accu-Chek test strips will have the option to continue at their current copay tier but OneTouch test strips will be the preferred product for new users.
    • OptumRx® is removing OneTouch test strips and adding Contour™ Next, which will be their preferred product.

Specialty Drugs

  • Multiple Sclerosis is a targeted category for specialty drug changes with CVS removing brand Tecfidera and covering the generic. OptumRx will remove Rebif offering Avonex or Betaseron as alternatives.
  • Express Scripts is reversing the formulary status of two drugs used for the treatment of moderate to severe plaque psoriasis and other inflammatory conditions. Cosentyx will be removed, and Taltz will be added as the preferred drug therapy in 2021. Plan sponsors will experience the high upfront costs for required loading doses of Taltz for patients who transition to the new preferred therapy.
  • Optum Rx also announced changes to their utilization management programs for specialty drugs, including quantity limits for drugs used for the treatment of hereditary angioedema (HAE) and Stelara.

Generics

  • Express Scripts and Optum Rx will remove all branded formulations of Albuterol HFA products, covering only the generic in 2021. This change represents a large portion of the member impact for these PBMs.
  • As generic Truvada (emtricitabine/tenofovir) is now available, Optum Rx will exclude both brand Truvada and Descovy; the only two FDA approved for HIV-1 pre-exposure prophylaxis (PrEP). Optum Rx will make the lower-cost generic Truvada the preferred drug for this use.
  • In a different approach, CVS is adding Oracea®, doxycycline monohydrate, used to treat rosacea to their Tier 1 strategy, which prefers the use of a brand name drug over a generic equivalent. It will join Adderall®, Concerta®, and Advair® on the Tier 1 strategy implemented last year. The addition of Oracea expects to deliver savings of 39 percent per claim.

Biosimilars

  • As the number of FDA approved biosimilars in the U.S. continues to increase, their presence in the market creates competition, which may drive savings.
  • Formulary changes for 2021 focus on one drug: Neulasta. It has four FDA approved biosimilar products.
    • Brand Neulasta will be removed for both CVS and Express Scripts.
    • CVS will cover one Neulasta biosimilar, Ziextenzo, while Express Scripts will prefer two Neulasta biosimilars, Ziextenzo and Fulphila.
    • Optum Rx will cover Ziextenzo, as well as brand Neulasta as their preferred products.

Headed into 2021, plan sponsors will be ever vigilant in their efforts to contain costs. The PBMs have put forward their proposed 2021 formulary changes to assist with these efforts. PSG is available to support clients as they navigate formulary changes with the Big Three PBMs, as well as other PBMs not featured here.  Please contact us to gain further insight into how PSG can help in your specific situation.

 

 

                   



Renee Rayburg helps lead Artemetrx services in Clinical Consulting with more than 23 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.