PBMs have used formulary exclusions as an effective way to negotiate with manufacturers for several years. However, at least one payer has gotten more aggressive with its tactics to get members to move from an excluded drug to one with preferred status, dangling a financial incentive for members. That effort is facing pushback from several medical associations, but if it proves to be successful, other companies could follow suit, suggest industry experts.
PBMs began implementing formulary exclusion lists about 10 years ago, and specialty drugs have made up an increasing number of the excluded products. As of early 2021, each of the Big Three — CVS Health’s Caremark, Cigna’s Express Scripts and UnitedHealth Group’s OptumRx — was excluding more than 400 products.
Earlier this year, Cigna began offering people on Novartis Pharmaceuticals Corp.’s Cosentyx (secukinumab) a $500 debit card if they switched from that agent — which moved from preferred to excluded status on Jan. 1 — to one of its preferred inflammatory treatments. Cosentyx is a human interleukin-17A antagonist approved for adult and pediatric plaque psoriasis, psoriatic arthritis, ankylosing spondylitis and non-radiographic axial spondyloarthritis. The company also has a nonpreferred formulary tier.