Specialty Drug List. From 1999 to 2017 I was a research associate professor at the Tufts Center for the Study of Drug Development. 2020 CVS/Caremark Formulary. Based on PHSI’s calculations, OptumRx leads the way with 246 new formulary exclusions. The higher the list price the greater the out-of-pocket spending by patients, given that the predominant form of cost-sharing, co-insurance, is calculated based on PBMs have maintained that rebates are passed through to plan beneficiaries by way of lower premiums. Some of key things to note from the PBM formulary exclusion for 2019 are discussed below. 2019-20 Plan Highlights. It suggests exclusions are more a function of horse-trading and rebating, rather than being evidence- and value-based. Although ESI has excluded the low-cost HIV option from its formulary, the PBM’s introduction of authorized low-cost alternatives though its newly launched National Preferred Flex formulary could be an advantage for its clients. Specifically, I analyze the value (costs and benefits) ofI'm an independent healthcare analyst with over 22 years of experience analyzing healthcare and pharmaceuticals. As a result, 10 multisourced branded drugs having direct generic equivalents, 11 specialty drugs, 24 single-source branded drugs with generic alternatives, and 12 branded drugs with a high net cost have been excluded from the PBM’s formulary.For drugs used to treat hepatitis C, the PBM is excluding AbbVie’s Mavyret and adding back Merck’s Zepatier as a preferred alternative in its 2019 formulary. CVS has also excluded two drugs, Prolastin-C and Zemaira, from its pulmonary enzyme deficiency class.CVS launched a new program that provides clients an opportunity to exclude any drug launched at a price greater than $100,000 per quality-adjusted life year (QALY). The medical provider should consult the drug This can be done using the QALY ratio determined by comparative analyses produced by the Institute for Clinical and Economic Review.In their formulary exclusions, ESI and CVS both have done some exclusions in their specialty categories. Value Formulary . We assume no responsibility for the actions or omissions of any medical provider based upon reliance, in whole or in part, on the information contained herein. PBMs then compel insurers and employers to use standard formularies by reducing the rebates offered to those who choose to adopt custom formularies without exclusions, which increases costs to the plan sponsor. However, these rebates and discounts are typically not shared with patients at the point-of-sale.Formulary exclusions can create additional barriers for patients who may experience challenges accessing prescribed treatments. I have also presented my work at numerous trade, industry, and academic conferences. PBMs Express Scripts and CVS Caremark are excluding 50 and 23 drugs, respectively, from their largest formularies for 2019. Even the threat of being removed from the formulary can lead to manufacturers offering steep rebates. necessity or formulary exception requests will be reviewed based on drug-specific prior authorization criteria or standard non-formulary prescription request criteria. Express Scripts estimates that its NPF, which covers 3,886 drugs, will save approximately $3.2 billion in 2019, or $10.6 billion cumulatively from 2014, on prescription drugs for payers.These new tools and techniques introduced by PBMs could change the exclusion strategy going forward. Exclusion Drug List. Empire Plan Flexible Formulary. Express Scripts and CVS Caremark annually release the list of excluded drugs from their largest national formularies. Often CVS Caremark preferred or recommended products are excluded by Express Scripts, and vice versa. 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