Upcoming 2021 Express Scripts Formulary Changes



Renee Rayburg, RPh, Vice President of Specialty Clinical Consulting
August 23, 2020

It’s that time of year again, and Express Scripts has released its list of formulary changes that will be effective January 1, 2021, for their clients. To date, 2020 has been a challenging year where balancing member access, affordability and choice becomes even more difficult. Unique times lead to unique measures. As such, when 44 drug exclusions went into effect on July 1, 2020, existing utilizers were grandfathered in. The July changes will be effective January 1, 2021, for the 0.11 percent of the grandfathered members who were impacted.

To provide “tighter management of drug trend categories,” Express Scripts is implementing 70 new drug exclusions for the National Preferred Formulary bringing their total number of excluded drugs to 422 out of 3,977. The changes include the exclusion of 14 specialty drugs and 11 drugs moving from preferred to non-preferred status. Looking across PSG book of business these formulary changes represent 6.3 percent impact to members and 2 percent impact on cost. All 70 exclusions will also apply to the National Preferred Flex Formulary.

With a focus on “highest spend categories,” Express Scripts made changes to these top categories:

Just one year ago, Taltz, was excluded with Cosentyx® as the preferred specialty drug. Both are IL-17 inhibitors used for the treatment of moderate to severe plaque psoriasis and other related inflammatory conditions. Both are self-administered as a subcutaneous injection but require a loading dose for new starts to therapy resulting in very high up-front costs, often $17,000 or more. In addition to member disruption, plan sponsors will be responsible for the high up-front costs for those members having to switch therapy.

Diabetes, a top category of spend for most plan sponsors, will see further narrowing of its type 2 diabetes (T2D) drugs when Januvia® and its combination products will be the only DPP4 inhibitor drugs to be covered. This results in the exclusion of Tradjenta® and its combination products which were preferred agents in 2020. There are multiple categories of T2D drugs available for use, many of which have recently shown additional cardiovascular clinical benefits offering many options for patients. In addition, diabetes is a category where changes are experienced and expected each year.

The removal of the brand albuterol HFA products, ProAir®, and Ventolin® will result in the most member disruption as it represents 83 percent of the formulary change member impact across our book of business. However, these inhalers all contain albuterol, so the formulary alternative represents the generic equivalent to the brand products, essentially the same drug. While this change affects a large volume of members, the disruption should be very minimal.

Express Scripts has incorporated the use of lower-cost generics as preferred agents for 53 of the 70 drug exclusions as well as biosimilars: Fulphila® and Ziextenzo®, for Neulasta®, an injection that is used to reduce the risk of infection in cancer patients who are using certain chemotherapy medications. Neulasta does offer a unique dosage form, Onpro®, which allows for ease of administration at home for cancer patients to avoid returning to the physician’s office the day after receiving chemotherapy. The biosimilars do not offer this unique dosage form, however, patients or caregivers can be taught to self-administer at home or coordinate with a home health care nurse to administer.

Lastly, efforts to continue to identify and remove egregiously priced drugs with sufficient clinically acceptable alternatives continue with the exclusion of several high priced oral contraceptives Safyral®, Quartette®, and Seasonique® as well as a couple branded topical retinoid acne products, Retin-A Micro® 0.1 percent, 0.04 percent, and Tazorac® 0.1 percent. However, these efforts are sub-optimal if branded combination drugs such as Vimovo® and Duexis® remain covered while their ingredients are available over the counter. Additional savings opportunities exist with the preferred coverage of high-cost generics, see the differences in costs for the five preferred antifungals, not to mention, the availability of an effective topical antifungal, Lamisil®, over the counter. More opportunities exist for cost savings.

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

Up next: Learn more about the 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.