By Jane Anderson
CVS Health Corp.’s Caremark will exclude 57 medications from its 2021 formulary and add six back. Meanwhile, UnitedHealth Group’s OptumRx subsidiary will exclude 19 medications and products while adding back five and implementing restrictions on others.
Still, only a handful of products excluded by either PBM are likely to impact many members adversely, says Marc Guieb, a pharmacist and consultant with Milliman Inc. That also applies to the exclusions announced earlier by Cigna Corp.-owned PBM Express Scripts, he adds.
Guieb observes that brand-name albuterol inhalers are seeing exclusions in 2021 from multiple PBMs, and that’s the change that will affect the most members. “That’s a big one this year,” he says. “One of the PBMs’ new strategies is, they’re completely excluding all the brands of albuterol inhalers, and they’re just going with the generic.”
Meanwhile, “the change that will actually cause the most widespread disruption and confusion will be diabetics switching to entirely new blood glucose monitoring systems, which is a hassle,” Guieb says.
PBMs that decide to prefer one specialty drug over another also can cause significant member disruption, Guieb adds, pointing to potential issues involving Novartis Pharmaceuticals Corp.’s biologic Cosentyx (secukinumab), which was excluded from Express Scripts’ 2021 formulary in favor of Eli Lilly and Co.’s Taltz (ixekizumab).
Overall, “I will say that for a lot of these annual formulary changes, they’re definitely a step in the right direction, although it may not be a big enough step in the right direction,” Guieb adds.
For 2021, OptumRx is evaluating Biogen’s multiple sclerosis drug Tecfidera (dimethyl fumarate) due to a generic launch. Biogen’s Vumerity (diroximel fumarate) remains excluded.
Brian Anderson, a principal at Milliman, tells AIS Health that the products added back by PBMs can be “just as interesting” as those excluded.
Caremark is adding back seven products, six of which are preferred. OptumRx is adding back the Accu-Chek glucose meters, along with Teva Pharmaceuticals USA Inc.’s ProAir inhalers, Anderson says.
Add-backs can confuse plan members, Anderson points out. “It’s really hard for a plan or employer to explain to their membership why a drug that was excluded last year is now covered again,” he says.