For 2026, Caremark (CVS Health), Express Scripts (Cigna), and Optum Rx (UnitedHealth Group) again excluded hundreds of drugs from their standard formularies, according to Drug Channels. The updates point to a clear shift: formulary preferences for Humira and Stelara are moving toward private-label biosimilars tied to each PBM’s corporate parent. Many of the preferred drugs now come with lower list prices, exposing the tension between rebate-driven economics and a slow but real rise in net-price competition. Exclusion counts have flattened at Caremark and Optum Rx yet still climbed at Express Scripts. The report calls these movements early indications of the transition to what it labels the Net Pricing Drug Channel (NPDC) era, where cost-plus reimbursement and direct-to-patient fulfillment begin to chip away at traditional PBM leverage.
This pattern matters because it signals that PBMs’ command over brand access is starting to fray as the gross-to-net price gap closes. Once lower-net, house-branded biosimilars replace the old high-rebate brands, PBMs pivot from spread capture to controlling the product margin itself. That’s not a small adjustment, it rewrites how employers and plan sponsors negotiate. According to the report, the combination of low-list pricing and direct distribution, pushed by new entrants like Mark Cuban’s venture and reportedly even by AbbVie, is compressing the rebate model’s long-protected margins. You can almost feel the discomfort in the old system.
If this NPDC transition holds, formulary exclusions stop being the blunt instrument they once were. Plan sponsors stand to gain transparency, less rebate revenue to hide behind, more exposure to where PBMs route products internally. That could make PBM contracts clearer, but also more uncomfortable to defend. Heading into the 2027 cycle, everything may depend on whether PBMs can keep their financial footing through vertical integration rather than rebate volume. I’ll be watching whether the country’s largest employers start rejecting the “standard” formularies outright and whether manufacturers borrow the private-label playbook in other therapeutic areas. Then we’ll know who’s really adapting, and who’s just rearranging the margins.
