Upcoming 2021 CVS Formulary Changes



Renee Rayburg, RPh, Vice President of Specialty Clinical Consulting
October 2, 2020

Understanding the importance of delivering “an effective formulary strategy” to achieve cost containment in these challenging times, CVS has revealed their 2021 formulary changes. While their focus is on “delivering value and quality care,” these changes offer the promise of cost savings for clients. Those aligned to CVS’ template formularies expect to see $4.4B in 2021, an estimated $130 savings per member.

CVS is committed to “ensuring members have affordable access to clinically appropriate medications,” and they estimate fewer than 0.9 percent of members will experience any changes from the formulary removals. Overall, the 2021 changes include 57 drug exclusions, six drugs added back, and one drug added to the Tier 1 strategy.

CVS – Standard Control Formulary #
New Exclusions for 2021 57
Number of Specialty Drugs 17
Positive Changes (add backs) 6
Member Impact % 1.4
Cost Impact % 3.1

 

The most considerable member impact involves the removal of Accu-Chek® test strips and the return of OneTouch® test strips, which were removed just two years ago in 2019. Members will transition back to OneTouch products. Blood glucose monitors are very similar, and switching between products is not expected to be difficult, but a change like this may confuse members. CVS will work with plan sponsors to minimize member disruption.

Oracea®, doxycycline monohydrate, is used for the treatment of rosacea. It will join Adderall®, Concerta®, and Advair® on the Tier 1 strategy, which prefers using a brand name drug over an equivalent generic. The brand drugs are available at a generic copay to the member, and the continuation of the original three brand drugs offers consistency for members. The addition of Oracea expects to deliver savings of 39 percent per claim.

Several formulary changes involve specialty drugs. Most notably, the coverage of generics only and removal of the brands for:

  • Tecfidera®, which is used for multiple sclerosis (MS); and
  • Tracleer®, which is used for pulmonary arterial hypertension (PAH).

Ziextenzo®, a biosimilar for Neulasta®, will be the preferred product in the neutropenia colony-stimulating factor category. Neulasta, Neulasta Onpro®, and Udenyca® will be removed. Learn more about Neulasta in PSG’s fourth annual State of Specialty Spend and Trend Report.

Changes to the highly rebatable growth hormone category include:

  • removal of Humatrope®; and
  • adding back Norditropin®, which will join Genotropin® as the preferred products.

Changes in the antidepressant category include:

  • removal of Paxil®, Paxil CR®, Pexeva®, and Viibyrd®;
  • leaving Trintellix® as the only branded Selective serotonin reuptake inhibitor (SSRI).

Changes in the miscellaneous respiratory agents class include:

  • removal of Aralast NP® and Glassia®;
  • Prolastin-C® will become the sole preferred drug for treating alpha-1 antitrypsin deficiency.

Another apparent focus for CVS continues to be managing hyperinflationary drugs. The 2021 formulary changes include the removal of calcipotriene/betamethasone. The cost per claim for this drug exceeds $1500.

Additionally, Turing Pharmaceutical’s drug, Daraprim®, can be considered the “poster-child” for price gauging due to its extreme price increase from $13.50 to $750 per tablet in 2015, now has a generic equivalent available. Pyrimethamine® has a list price of about half of that of Daraprim. CVS will remove the brand Daraprim.

For current PSG clients, reach out to your account team for assistance and questions. Reach out to [email protected] for more information.

UPDATE: On October 9, 2020, CVS added an additional change with the grandfathering in of current users of test strips and Trulance and only applying the change to new users. We expect this to impact plans by decreasing the impact of the change for January 1, 2021 as the test strips are the biggest category of impact.

Up next: Learn more about the Express Scripts and OptumRx formulary changes for 2021.



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.