It’s back…PHSL’s annual review of the big 3 PBM formulary exclusion list updates! Express Scripts (ESI), CVS Caremark, and OptumRx published their formularies and exclusions for January 2025. Based on PHSL’s review, CVS Caremark’s Standard Control formulary excluded an additional 33 drugs in 2025, while ESI’s National Preferred formulary excluded an additional 19 drugs. OptumRx’s Premium formulary adds 12 new exclusions and removes 3 products, adding them back on the formulary. Although CVS Caremark leads in the number of new exclusions, the company anticipates that 99.4% of their members will not be impacted by these formulary removals. The January 2025 exclusions, as researched by PHSL, are as follows:

During the review, PHSL made the following observations:

Adalimumab

• As of 2025, all three PBMs will exclude Humira. Instead, each PBM will favor their own private-label companies as part of their biosimilar strategy. The adalimumab strategy for each PBM is as follows:
  • In 2024, CVS Caremark removed Humira (AbbVie) and Amjevita (Amgen) from the formulary and added Cordavis’ Hyrimoz and adalimumab-adaz to the formulary.  Cordavis, Hyrimoz and adalimumab-adaz will remain the only adalimumab products on the 2025 formulary. Note that Cordavis is a CVS Health subsidiary.
  • ESI’s 2024 formulary included Humira (AbbVie) and Hyrimoz (Sandoz) but excluded the Cordavis versions of these products upon launch later that year. For 2025, ESI will also exclude Humira (AbbVie) and Hyrimoz (Sandoz). Humira biosimilars remaining on ESI’s 2025 formulary include:
    • Cyltezo (Boehringer Ingelheim)
    • adalimumab-adbm (Boehringer Ingelheim & Quallent)
    • adalimumab-adaz (Sandoz)
    • Simlandi (Teva)
    • adalimumab-ryvk (Quallent)
    • Note that Quallent is a private-label distributor owned by Cigna.  Quallent has an agreement with Boehringer Ingelheim to manufacture adalimumab-adbm and an agreement with Teva for adalimumab-ryvk.
  • In 2025 OptumRx will exclude Humira (AbbVie), Cyltezo and adalimumab-adbm (Boehringer Ingelheim), Hyrimoz and adalimumab-adaz (Sandoz), and Amjevita 0/0.2ML, 40/0.4ML, 80/0.8ML strengths (Amgen). The only Humira formulary alternatives left in 2025 are currently listed as Amjevita (Amgen and Nuvaila). Nuvaila is OptumRx’s new biosimilar procurement business and private label generics manufacturer. OptumRx has noted that members currently taking Humira may continue on therapy until Amjevita receives an interchangeability designation.

Obesity & Diabetes

• Obesity and Diabetes products are a focus this year for all three PBMs.
  • ESI has now excluded Saxenda in favor of preferred alternatives Wegovy and Zepbound, likely due to rebates. Optum has added Wegovy to its premium formulary.
  • Optum now excludes Victoza in favor of formulary alternatives Mounjaro and Ozempic, among four others.
  • CVS Caremark is excluding the biguanide antidiabetic products, Fortamet and Glumetza (both branded and generic versions), as well as metformin 625mg. PHSL suspects the latter is excluded as generic metformin 625mg is a high-cost product where similar low-cost strengths exist.

 Respiratory Products

• ESI added a new category of drug class exclusions, Alpha1 Proteinase Inhibitors for emphysema, in 2025. The excluded products are Aralast NP, Glassia, and Zemaira, with Prolastin C as the only preferred alternative listed for this drug class. In addition, Karbinal ER Suspension, an oral antihistamine, is also newly excluded in 2025, with several generics listed as preferred alternatives.

 Migraine

• CVS Caremark excluded five branded products in favor of generic NSAIDs and triptans. Excluded brands include Cambia, Ergomar, Migranal, Trudhesa, and Treximet. However, the 2025 formulary continues to include two branded triptans, Onzetra Xsail and Zembrace SymTouch.

 Generics Strategies

• Similar to their migraine strategy, another category of CVS Caremark exclusions appears to be focused on utilizing generic NSAIDS across disease states to exclude branded products.
  • One set of such exclusions focused on both branded and generic NSAID-combination products, instead suggesting that the patient separately take the NSAID and the alternative generic products together. In addition to the aforementioned Treximet exclusion, newly excluded Vimovo (naproxen and esomeprazole) and Duexis (ibuprofen and famotidine), which are both indicated for arthritis with ulcer prophylaxis, fall into this category.
  • Another CVS Caremark set of exclusions replace a branded product with generic diclofenac, as is the case with Pennsaid 2% (osteoarthritis) and Zipsor (acute pain).
• Both CVS Caremark and ESI exclude specific high-cost strengths of certain generic products.
  • In line with the lower-cost generic strengths strategy for metformin (see Obesity & Diabetes, above), CVS Caremark is excluding specific strengths for three other generic products. Allopurinol 200mg tablets (2 manufacturers), baclofen 15mg tablets (2 manufacturers), and zolpidem 7.5mg capsules (1 manufacturer) are all excluded, while the other strengths of these products are not.
  • ESI also chose to now exclude baclofen 15 mg tablets and allopurinol 200mg tablets. We expect that the limited manufacturers for the above product strengths result in product costs that are relatively higher than the other respective product strengths of the same chemical entity.
• Optum now excludes Cardizem, Emflaza, and Syprine, stating the rationale that each brand has generic equivalents covered on Tier 1.

 Formulary Add-Backs

• Optum chose to bring three products back onto its formulary, including two immune globulin (human) products, Cutaquig and Panzyga, as well as Auryxia, a brand formulary alternative to the newly excluded Velphoro. There are also several generic formulary alternatives listed for Velphoro.
• ESI added previously excluded Fabrazyme (enzyme replacement therapy) back to the 2025 formulary.

Each of the major PBMs have taken a different approach to managing drug expenditure in 2025, with formulary exclusions continuing to play a significant role. PBMs exclude products for both clinical and financial reasons. Each PBM makes value judgements and determines what coverage is no longer warranted. This article represents PHSL’s analysis of publicly available information regarding the three PBM’s formulary exclusion for 2025. Readers are encouraged to assess the lists for themselves, using the formulary and exclusion list source information provided in the links below.

CVS Caremark 2025 Standard Control Formulary

ESI National Preferred Formulary 2025 Exclusions

OptumRx 2025 Premium Standard Formulary

 

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