Eli Lilly and Co.'s osteoporosis drug Forteo and Amgen Inc.'s post-cancer treatment Neupogen will not be covered in 2018 by Express Scripts Holding Co., the U.S.'s largest pharmacy benefit manager.

The company, which acts as the middleman between pharmaceutical manufacturers and insurance plans covering 83 million people, released its 2018 national preferred formulary on July 31.

A Synergy Pharmaceuticals Inc. irritable bowel syndrome drug Trulance has also been left off the list.

The manufacturers of these drugs did not provide competitive discounts during negotiations, Express Scripts spokesperson Phil Blando told S&P Global Market Intelligence. The full list includes 64 new exclusions, many of which are for drugs that have generic alternatives on the market. Excluding the drugs means Express Scripts-covered patients will not have access to them and may need to switch medications unless they have a rare clinical need, the company said in a statement.

In place of Neupogen, Express Scripts recommended Zarxio, a biosimilar from Novartis AG's Sandoz unit, and Teva Pharmaceutical Industries Ltd.'s Granix, another bone-marrow stimulating drug for cancer patients.

Instead of Forteo, the company selected a range of generics and Radius Health Inc.'s Tymlos.

Mylan's EpiPen, EpiPen Jr. and its generic version of the injectable drug for allergic reactions and asthma are all on Express Scripts' preferred list, while a generic version made by A-S Medication and Impax Laboratories Inc. is excluded, as is a similar drug from Kaléo Pharma. Blando said EpiPen's average wholesale price is $600, while Kaléo's Auvi-Q averaged $4,500.

The new exclusions will affect fewer than 1% of its members, the pharmacy benefit manager said.

Several opioids have been excluded, including Opana ER from Endo Pharmaceuticals, which was recently pulled off the market, and the generic oxycodone ER. Purdue Pharma LP's OxyContin, an oxycodone formulation designed to discourage abuse of the drug, is on the preferred list, along with Purdue's Hysingla ER and Depomed Inc.'s Nucynta ER, which also have abuse-deterrent qualities.

Other opioid medications derived from fentanyl — Fentora from Teva, Lazanda from Depomed and Abstral from Sentynl Therapeutics Inc. — are excluded, with generic fentanyl citrate lozenges listed as the preference.

Amgen's Neupogen has already seen biosimilar competition eat into sales, which declined 30% year over year in the second quarter, according to Anthony Hooper, Amgen executive vice president of global commercial operations. The drug held 44% of its competitive market at the end of the half year, Hooper said on the company's July 26 earnings call.

Eli Lilly's Forteo recently received a low cost-effectiveness grade by the Institute for Clinical and Economic Review, which said its price would need to be reduced by 86% to 89% to fall into the range of less expensive generic osteoporosis treatments; Tymlos, by comparison, would need to be reduced 59% to 68%. Along with pharmaceutical companies, pharmacy benefit managers often provide feedback to ICER draft documents and help shape final reviews.

Express Scripts will provide its full formulary list on or by Sept. 15, which may feature more exclusions. Blando said the company does not anticipate any drugs being removed from the already available exclusion list.