Formulary Win/Loss Log — YTD 2026
Maintained by the Payer Account Lead. Updated within 24 hours of any tier-status change at a tracked plan. Distribution: Market Access leadership, Launch Lead, Sales Operations, KAM leadership.
Summary
Through May 15, 2026, the Zenvara formulary book reflects 18 wins (tier 2 preferred or better) across 23.5M covered lives, two losses (Humana Gold Plus, BCBS Minnesota) and one step-edit imposition (Florida Medicaid AHCA) attributed to competitor X. Net change YTD: +9.9M lives versus end of 2025 baseline. The single largest move this YTD is the Cigna Open Access Plus win confirmed May 14 (+14.1M lives, effective July 1, 2026).
This week (Week 19, 2026)
WIN — Cigna Open Access Plus: Tier 3 preferred with prior authorization only. Effective July 1, 2026. Lives impacted: +14.1M commercial. Confirmed by Aisha in #market-access-payers Thursday afternoon. KAM account: Karen Holmes. Contracting terms: standard manufacturer rebate of 18%, target-discount agreement on net price erosion through 2027.
LOSS — Florida Medicaid AHCA (Florida Agency for Health Care Administration): Zenvara moved from preferred to non-preferred on the May 11 Preferred Drug List refresh. Step-edit through competitor X imposed. Lives impacted: -4.2M Medicaid. State PDL refresh landed on Sunday and was not registered internally until the following Friday — a process gap that has been escalated to internal monitoring for remediation.
Net week 19: +9.9M lives.
All wins YTD 2026
Cigna Open Access Plus (May 14): tier 3 preferred, PA only. +14.1M commercial. (This week.)
Express Scripts 2026 NPF (May 5): tier 3 preferred with PA. +12.0M lives across all books that use ESI as PBM.
Aetna Medicare Advantage (Apr 28): preferred tier with PA. +3.4M Medicare. (Recovery from earlier provisional non-formulary status.)
BlueCross BlueShield Federal Employee Program (Apr 15): preferred tier with PA. +5.3M commercial.
Highmark BCBS (Apr 8): tier 3 preferred with PA. +6.1M commercial.
UHC Community Plan (Apr 1): preferred tier with PA. +7.2M Medicaid Managed Care.
HCSC (BCBS Illinois + Texas + Oklahoma + Montana + New Mexico) (Mar 22): tier 3 preferred with PA. +7.4M commercial.
Anthem BCBS PPO (Mar 15): tier 3 with PA + ST. +22.4M commercial. (Largest single win YTD before Cigna.)
Florida Blue (Mar 8): tier 3 preferred with PA. +5.0M commercial.
Kaiser Permanente (Mar 1): preferred tier with PA. +12.6M commercial. (Notable: Kaiser is integrated; placement is on the Kaiser formulary directly rather than through a PBM.)
Centene Ambetter (Feb 22): tier 3 preferred with PA. +3.8M Health Exchange.
UnitedHealthcare Choice Plus PPO (Feb 15): tier 3 preferred with PA. +27.5M commercial. (Largest YTD by lives.)
Centene WellCare (Feb 8): preferred Medicare with PA. +4.5M Medicare.
CVS Caremark SilverScript (Jan 30): preferred Medicare PDP with PA. +5.7M Medicare PDP.
Express Scripts Medicare (Jan 22): preferred Medicare PDP with PA. +4.1M Medicare PDP.
Aetna Open Access PPO (Jan 15): tier 4 with step-therapy through pembrolizumab. +17.2M commercial. (Note: classified as a win because Aetna is on the formulary, but the step-therapy through pembrolizumab limits prescribing autonomy.)
Molina Healthcare (Jan 8): preferred Medicaid Managed Care with PA. +5.1M Medicaid.
Aetna Better Health (Jan 4): preferred Medicaid Managed Care with PA. +2.9M Medicaid.
All losses YTD 2026
Florida Medicaid AHCA (May 11): moved from preferred to non-preferred; step-edit through competitor X. -4.2M Medicaid. (This week.)
Humana Gold Plus HMO (Apr 15): non-formulary; exception process only. -8.9M Medicare Advantage.
BCBS Minnesota (Mar 22): step-therapy required through competitor X. -4.6M commercial. Filed an appeal in late March; outcome pending.
Watch items (potential losses)
Express Scripts 2027 NPF refresh: due to be finalized August 2026 for 2027 effective date. Probability of step-edit imposition: estimated 70%. Estimated impact: -15M to -22M effective lives YoY.
Anthem closed-formulary states: probability that Anthem moves to closed formulary in 4 BCBS-aligned states (IN, KY, OH, VA) in 2027 cycle: estimated 60%. Estimated impact: -11M to -14M lives YoY.
CVS Caremark step-edit reinforcement: probability that CVS strengthens the existing step-edit in the 2027 NPF: estimated 40%. Estimated impact: -8M to -12M effective lives YoY.
Process notes
All wins and losses are reflected in the next MMIT digest (typically 5-15 day lag from the formal decision). Internal tracking should not rely on MMIT alone; the Payer Account Lead's direct relationships with PBM contracting and individual plan formulary teams are the primary source.
State Medicaid PDL refreshes are monitored weekly via Florida AHCA, Texas HHSC, California DHCS, New York DOH, Ohio DODD, and Pennsylvania DHS published feeds. The Florida miss this week prompted a process review; we will switch to daily monitoring on Sundays for the next quarter.
Cross-references
2026 US Payer Landscape Brief (1D2…), Weekly Launch Tracker WK19 (1A2…), Payer Objection Handling Playbook (1F1…).