Excluded in 2016: These Drugs Are On the Outside Looking In

Express Scripts and CVS have come out with their national formularies for 2016—and the list of drugs and other products (blood glucose test strips, for example) that didn’t make the cut and are newly excluded from the list of covered drugs.

Uncovered

Additions to the list of drugs excluded from the 2016 national formularies of Express Scripts and CVS.

Express Scripts is excluding 80 medications in 2016, an increase of eight from the number on the 2015 list of excluded drugs. The newly excluded drugs include two diabetes drugs, Kombiglyze XR and Onglyza; Synvisc, the injection for arthritic knees; and Qsymia, the weight-loss drug. The country’s largest PBM (as measured by the number of prescriptions processed) says the exclusions will save its national preferred formulary customers about $1.3 billion in 2016 and that less than 1% of the people covered by those clients will be affected by the change. Express Scripts also put 10 excluded drugs back on its formulary, including Betaseron, a multiple sclerosis drug; Tradjenta, a diabetes drug; and Zohydro ER, the controversial long-acting opioid. CVS has 93 products on its 2015 excluded list and is adding 31 more in 2016 (that count might be slightly misleading because slight variations of a drug sometimes get their own listing). The newcomers to the excluded list include Abilify, an antitypical psychotic; Intuniv, an ADHD drug, and Viagra (CVS covers Cialis instead). A spokesman for the company said in an email that CVS “led the PBM industry” when it introduced a formulary strategy in 2012 that excluded “certain expensive branded drugs.” The formulary exclusions, the email continued, allows the company to “deliver significant savings to both the payer and the patient without compromising overall health outcomes.”

Prime Therapeutics, the Minnesota PBM owned by Blues plans, doesn’t publish a single list of drug exclusions because the exclusions vary with the client. “We believe our tailored approach is highly competitive with other PBMs in the industry,” a spokesperson wrote in an email.