It’s back…PHSL’s annual review of the big 3 PBM formulary exclusion list updates! PHSL reviewed Express Scripts (ESI), CVS Caremark, and OptumRx formulary exclusions for January 2026. Based on PHSL’s review, CVS Caremark’s Standard Control formulary excluded an additional 16 drugs in 2026. OptumRx’s Premium formulary adds 12 new exclusions and brings 1 formerly excluded product back on the formulary. The biggest changes were on ESI’s National Preferred formulary, which added 129 exclusions, compared to 19 last year, according to PHSL’s 2025 analysis. ESI also added two formerly excluded drugs back onto their formulary in 2026.

The January 2026 new exclusions, as researched by PHSL, are as follows:

During the review, PHSL made the following observations:

While CVS Caremark and Optum were relatively on par with 2025 in terms of the number of new exclusions they added in 2026, ESI took a broader approach to pare down its formulary, adding nearly 130 brand and generic drugs to its exclusion list.

By the Numbers

• As expected, brand products with generic equivalents on the formulary were added to the exclusion list:
  • ESI: 6 products (5% of new exclusions)
  • CVS Caremark: 3 products (20% of new exclusions)
  • Optum: 9 products (75% of new exclusions)
• We saw ESI simplify offerings within many drug classes by excluding 25 generic products.
• This number includes the 10 generic equivalent exclusions discussed below (see “ESI – Exclusions of Brands Along with Their Generic Equivalents”).
• This number does not include the specific generic strength and dosage form exclusions discussed below (see “Strength and Dosage Form Exclusions Strategy”).

ESI – NSAIDs

• Similar to the action CVS Caremark took in 2025, in 2026 ESI excluded several combination NSAIDs and NSAIDs that have generic alternatives, instead preferring that the patient separately take the individual generic or alternative generic products together. A few examples:
  • Combogesic (ibuprofen-acetaminophen tablet or IV solution) is excluded in favor of ibuprofen plus acetaminophen.
  • Ibuprofen/famotidine is excluded in favor of ibuprofen tablets plus famotidine tablets.
  • Naproxen/esomeprazole magnesium is excluded in favor of naproxen ec tablets plus esomeprazole magnesium capsules.
  • Sprix (ketorolac tromethamine) is excluded in favor of “generic oral nonsteroidal anti-inflammatory drugs.”

ESI – Exclusions of Brands Along with Their Generic Equivalents

ESI excluded 10 brands along with their generic equivalents for a total of 20 exclusions in this category. These exclusions are: antiviral Denavir (penciclovir), antimigraine agent Treximet (sumatriptan/naproxen sodium), diuretic Dyrenium (triamterene), antifungal Naftin (naftifine), DPP-4 inhibitor Zituvimet and Zituvimet XR (sitagliptin/metformin, sitagliptin/metformin ER), antihistamine Dymista (azelastine/fluticasone), proton pump inhibitor Dexilant (dexlansoprazole), antiglaucoma agents Travatan Z (travoprost drops) and Zioptan (tafluprost drops), leukotriene pathway inhibitor Zyflo (zileuton ER). PHSL ponders a selection of these excluded brand/generic equivalent pairs:

• In the case of Zituvimet and Zituvimet XR, Janumet and Janumet XR are now the only preferred brand alternatives (with saxagliptin/metformin also listed as a preferred alternative) in the DPP-4 Inhibitors and Combinations drug class. Since Januvia, Janumet, and Janumet XR all have reduced WAC pricing in 2026, this preference is likely due to the significant drop in claim ingredient costs for these brands.
• However, not all brand exclusions are related to favoring a different brand. For example, the preferred alternatives to the Zyflo (zileuton ER) exclusion are two generics (montelukast and zafirlukast). In the case of Dymista (azelastine/fluticasone), the preferred alternative is azelastine nasal plus fluticasone nasal, similar to their approach with combination NSAIDs.

Brand Exclusions with Same (Generic) Active Ingredient as Preferred Alternative

ESI (total of 5) and CVS Caremark (total of 2) both have added brand exclusions that do not have a generic equivalent on the formulary; however, a product with the same active ingredient is listed as a preferred alternative. Examples of these include:

• ESI: sickle cell disease agent Xromi (hydroxyurea oral solution) is excluded with other dosage forms of hydroxyurea preferred.
• ESI: antipsychotics Invega Sustenna and Invega Trinza are excluded with Erzofri, which has a different dosing schedule, listed as preferred.
• CVS Caremark and ESI: antipsychotic Opipza oral film is excluded with aripiprazole ODT or oral solution preferred.
• CVS Caremark and ESI: benign prostatic hyperplasia agent Tezruly (terazosin HCl oral solution): Both list generic terazosin, available as oral capsule, as the preferred agent.

Strength and Dosage Form Exclusions Strategy

All three PBMs excluded specific strengths of certain generic products. We expect that these strengths carried product costs that are relatively higher than the other respective strengths of the same chemical entity, generally due to the limited number of manufacturers for these products.

• Optum added one new exclusion of this type, doxycycline 40mg capsule DR (6 manufacturers).
• Half of CVS Caremark’s 16 new exclusions were for a specific drug strength, including the following branded and generic products:
  • Brands: Coxanto 300mg capsules, Combogesic 97.5/325mg tablets, Dolobid 250mg and 375mg tablets, and Gabarone 100mg and 400mg tablets. In comparison, ESI fully excluded all strengths of Combogesic, Dolobid, and Gabarone.
  • Generics: metformin 750mg tablets (2 manufacturers), ondansetron 16mg ODT tablets (1 manufacturer), metaxalone 640mg tablets (1 manufacturer), and glimepiride 3mg tablets (1 manufacturer). ESI also excluded metaxalone 640mg tablets and glimepiride 3mg tablets this year.
• In 2026, ESI added back previously excluded baclofen 15mg tablets (2 manufacturers) as a preferred alternative to the formulary. ESI also added 8 new specific strength product exclusions, all of which were supplied by only one manufacturer, with the exception of the topiramate 50mg sprinkle capsules (5 manufacturers):
  • Bisoprolol fumarate 2.5mg tablets
  • Clobetasol 0.025%
  • Glimepiride 3mg tablets
  • Labetalol 400mg tablets
  • Metaxalone 640mg tablets
  • Metronidazole 125mg tablets
  • Topiramate 50mg sprinkle caps
  • Tramadol 75mg tablets
• ESI also added 5 specific dosage form exclusions:
  • Ciclopirox 8% treatment kit (ciclopirox 8% topical solution preferred)
  • Dapsone 7.5% gel tube (pump preferred)
  • HUMALOG vial (cartridge, Kwikpen, Junior Kwikpen preferred)
  • Oxycodone coated tablets (uncoated tablets preferred)
  • Zepbound vials (pens preferred)

Biosimilars

ESI excluded several biosimilars in 2026:

• Herceptin biosimilars Kanjinti and Trazimera are excluded, with Hercessi and Ogivri listed as the preferred alternative on the 2026 formulary.
• Soliris biosimilar Bkemv is excluded, with Epysqli listed as the preferred alternative on the 2026 formulary.
• Actemra joins Tofidence on the exclusion list, with biosimilar Tyenne as the preferred alternative.
• Remicade biosimilar Inflectra is excluded, with biosimilar Avsola and infliximab as the preferred alternatives.
• Humira interchangeable biosimilar Cyltezo is excluded, leaving the following biosimilars on the preferred alternative list[1]:
  • Stelara, along with its biosimilars Otulfi, Steqeyma, Pyzchiva, and Wezlana, are excluded, leaving the following on the preferred alternative list:
    • Stelara biosimilars: Selarsdi, Yesintek, ustekinumab-TTWE (by Quallent)
    • Other Biologics: Entyvio, Omvoh, Skyrizi, Tremfa
      • Adalimumab-adbm (Boehringer Ingelheim & Quallent)
      • Adalimumab-adaz (Sandoz)
      • Simlandi (Teva)
      • Aadalimumab-ryvk (Quallent)

Dermatological Agents

ESI removed twelve dermatological agents, six brands and six generics. None of the excluded brands have an exact generic equivalent on the formulary’s preferred alternatives list, but there are several generic options left on the formulary that have the same active ingredient.

• For one example, Epsolay (benzoyl peroxide cream) was excluded and benzoyl peroxide remains on the formulary in gel form.
• For another example, Emrosi (minocycline HCl micronized ER) was excluded with generic minocycline listed as the preferred alternative.

 Formulary Re-Additions

• Optum added previously excluded Emgality, an antimigraine agent, back to the 2026 formulary, a brand formulary alternative to the newly excluded Ajovy.
• ESI previously excluded two products that were added back to the formulary: baclofen 15mg tablets and solution, and Hemangeol (propranolol hydrochloride oral solution).

Each of the major PBMs have taken a different approach to managing drug expenditure in 2026, 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 when coverage is no longer warranted. This article represents PHSL’s analysis of publicly available information regarding the three PBM’s formulary exclusion for 2026. Readers are encouraged to assess the lists for themselves, using the formulary and exclusion list source information provided in the links below.

 

CVS Caremark 2026 Standard Control Formulary

ESI National Preferred Formulary 2026 Exclusions

OptumRx 2026 Premium Standard Formulary

 

[1] 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.

 

Winter 2026 Newsletter:

How AI Could Change the Future of PBM Contracting