It’s formulary update season, which means pharmaceutical benefit managers (PBMs) and health plans will be making their lists and patients, providers and pharmacists will be checking them twice to see what medication coverage changes are coming Jan. 1.
Drug formularies, which have a long history in the United States, are a list of prescription drugs covered by a PBM or another insurance plan offering prescription drug benefits. Typically, a plan’s pharmacy and therapeutics team reviews new and existing drugs based on safety, quality and cost-effectiveness. They also consider drug alternatives and reimbursement.
Health plans exclude drugs from their formularies for many reasons, including encouraging patients to use a different drug in a therapeutic class, over-the-counter availability, a new generic option or concerns about safety or effectiveness.
Formulary changes can affect care team workloads after the Jan. 1 activation date due to an increase in prior authorization (PA) volume. At 20 minutes per manual transaction, and even 8 minutes per electronic PA request, this can mean hours of extra work each week for providers and pharmacists. For patients, it can mean waiting longer for their prescriptions to get filled or having to pay more for out-of-pocket costs.
Noteworthy for 2023 overall will be the presence or absence of biosimilars on formularies. Several significant launches are expected in 2023, including competition for Abbvie’s Humira, the most profitable drug in the world for over a decade. Seven biosimilars of the blockbuster drug have received FDA approval, and plans will have to decide if and what to include on formulary. Humira biosimilars alone could generate nearly $20 billion in savings by 2025. Biosimilars on the whole represent an average 30-40% off the list price of their reference products, which means payers will likely keep a close eye on them in the coming years.
Below, we’ve compiled notable formulary updates coming in 2023 for the nation’s largest prescription plans.
CVS Caremark Commercial 2023 updates
Caremark’s formulary shuffling removed 26 products from its list and added 31 products. The company estimates these updates will save each patient who aligns to the formulary $123.
Notable removals include Genentech’s Esbriet (pirfenidone) for idiopathic pulmonary fibrosis in favor of Sandoz’s generic pirfenidone. Caremark also prefers Boehringer-Ingelheim’s OFEV (nintedanib) over Esbriet, which also treats idiopathic pulmonary fibrosis, in addition to other lung diseases.
Takeda’s Velcade (bortezomib) for multiple myeloma and mantle cell lymphoma was also removed, in favor of newly launched generic, bortezomib by Fresenius Kabi. Additional removals include asthma medications: GlaxoSmithKline’s Arnuity Ellipta (fluticasone furoate), Flovent Diskus (fluticasone proprionate) and Teva’s QVAR Redihaler (beclomethasone diproprionate).
Additions include new and first-in-class therapeutics such as Insulet’s new infusion pump, the Omnipod 5. Others include:
• Leo Pharma’s biologic Adbry (tralokinumab-ldrm) for atopic dermatitis, • AbbVie’s Qulipta (atogepant), an oral calcitonin gene-related peptide (CGRP) antagonist, or “gepant,” for migraine treatment • Amgen and AstraZeneca’s Tezspire, the first biologic for severe asthma • Sol-Gel Technologies’ Twyneo for acne.
For 2023 updates beyond drug formulary lists: "4 Ways to Support Patients Navigating Annual Benefits Changes."
Express Scripts National Preferred Flex Formulary 2023 updates
For 2023, Express Scripts announced 43 new exclusions from its formulary.
Similar to Caremark, Express Scripts will exclude Genentech’s Esbriet for idiopathic pulmonary fibrosis in favor of Sandoz’s generic pirfenidone and Boehringer-Ingelheim’s OFEV.
Express Scripts has also excluded multiple diabetic supply manufacturers to align with a single manufacturer, Becton Dickinson.
Other specialty drug exclusions include Samsca (tolvaptan), Thiola (tiopronin), Cystadane (betaine) and Sabril (vigabatrin) in favor of lower-cost generics.
Notably, Express Scripts added Arcutis Biotherapeutics’ Zoryve (roflumilast) to its formulary in November 2022. Zoryve, a steroid-free cream for plaque psoriasis, received FDA approval in July 2022 and launched just a month later. While it won’t require prior authorization, Express Scripts will require two therapy steps prior to eligibility, including a generic steroid and a vitamin D analog.
OptumRx 2023 updates
OptumRx will exclude 19 drugs from its formulary in 2023.
Like its counterparts, OptumRx will exclude Genentech’s Esbriet for idiopathic pulmonary fibrosis and include Sandoz’s generic pirfenidone and Boehringer-Ingelheim’s OFEV.
Other notable exclusions in favor of cost-saving generics include AbbVie’s Combigan (brimonidine tartrate-timolol maleate), a glaucoma eyedrop, Pfizer’s Toviaz (fesoterodine fumarate) for overactive bladder and several ADHD medications.
Many of the formulary updates from OptumRx are in the form of utilization management shifts, or specific rules that affect how and when a drug is covered by the plan. This includes five medications that now require PA, 10 therapeutic categories with new step requirements and seven medications with quantity limits.
OptumRx was the first PBM to state it will include a Humira biosimilar on its formulary. Amgen’s Amjevita, will be included on its formulary in January 2023. The PBM also moved Enbrel, a Humira competitor for some time, back to preferred position on formulary. This could take more market share from Humira and potentially bring more cost savings to OptumRx and its beneficiaries.
PA requests are unavoidable, but there are ways to save time
When health plans make yearly changes to their formulary lists, providers and care teams typically face an increase in PA requests. Time-saving tools like electronic PA (ePA) can help organize and manage PA for all medications and health plans, which helps the process work more efficiently.
PA requests submitted electronically save care teams 12 minutes per request compared to phone or fax. With an ePA solution like CoverMyMeds, providers can also get alerts on medications with new PA requirements following a formulary update, which can help patients get the medications they need faster.
Read more about benefits verification season and how care teams can make it through more efficiently.