 Expert insights by Dr. Adam J. Fein on pharmaceutical economics and the drug distribution system (RSS feed) For 2026, the three largest pharmacy benefit managers (PBMs)—Caremark (CVS Health), Express Scripts (Cigna), and Optum Rx (United Health Group)—have once again excluded hundreds of drugs from their standard formularies. Our updated counts appear below.
The 2026 lists highlight how formulary preferences for Humira and Stelara are dominated by private-label biosimilars affiliated with the same parent companies that operate the three largest PBMs. Many of the preferred products feature lower list prices, signaling growing tension between traditional rebate-driven formularies and emerging net-price-based competition.
These developments matter because the pricing system that underpins PBMs’ formulary leverage is weakening. The gross-to-net bubble is deflating and the industry is moving toward what we call the Net Pricing Drug Channel (NPDC).
As low list prices, direct-to-patient distribution, and cost-plus reimbursement models gain traction, formulary exclusions will no longer deliver the economic power they once did. These changes threaten PBMs’ leverage—and profits.
As usual, Mark Cuban is leading the way. AbbVie itself now appears to be following. Consider this year’s formulary review a preview of what market access looks like when the rebate game starts to unwind.
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