After seeing their products being rejected in recent years by reimbursement agencies overseas, pharmaceutical manufacturers are suffering the same fate in the U.S., as PBMs refuse to include a growing list of drugs on their formularies.  The country’s largest PBM, Express Scripts, recently announced that 48 products, including a range of new and older drugs, will not be covered on the National Preferred Formulary for 2014.  While this action is estimated to affect “a mere” 600,000 -800,000 patients, it will have a significant impact on certain products — especially those trying to establish themselves in the market.  Established products will also take a hit, as evidenced by Novo Nordisk’s expectation that corporate earnings will be reduced by about 3% as a result of losing Express Scripts’ business for two of its largest drugs. Indications are that this trend will continue to grow and the barriers will get higher.  CVS/Caremark, the second largest PBM in the U.S., has already said it will be adding to the 34 products it blocked last year.