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Novo Nordisk’s Victoza, a diabetes treatment that dominates its class of drugs, was shunned by pharmacy benefit manager Express Scripts Holding Co. for at least the second year in a row, signaling that the Danish company refused to concede on pricing.

Competing drugs from AstraZeneca and Eli Lilly remained on the preferred list for 2017, while GlaxoSmithKline’s Tanzeum was also left off, according to a document published by Express Scripts on Monday. Separately, French drugmaker Sanofi’s blockbuster insulin Lantus was among products excluded from CVS Health Corp.’s 2017 list of covered drugs. Shares of Novo and Sanofi slumped on Tuesday in Europe.

Employers, insurers and other customers pay Express Scripts and CVS to keep the cost of drugs in check by switching patients to generic versions of medicines, and by pitting manufacturers of branded drugs against each other to get coverage.

Last year, diabetes was the most expensive category for treatment after specialty medications for illnesses such as cancer and rheumatoid arthritis in the U.S., according to Express Scripts.

Victoza, the market leader among drugs known as GLP-1 analogs that stimulate insulin production, is forecast to generate sales of $3.09 billion this year, according to analysts’ estimates compiled by Bloomberg.

The treatment in June demonstrated that it also helped reduce the risk of heart attacks, strokes and deaths from cardiovascular causes in diabetics, though the benefit was smaller than some analysts had expected.

“This development is surprising,” Citigroup analysts in London including Peter Verdult wrote in a research note on Tuesday, commenting on Victoza being excluded.

“Sentiment near term will be driven by market perception on Novo’s success in contracting for 2017 as well as the rebates required to grant access.”

A spokeswoman for Bagsvaerd, Denmark-based Novo declined to comment on the decision by Express Scripts. Jack Cox, a spokesman for Sanofi, said the drugmaker was disappointed by the CVS decision, but would continue talks with other insurers.

Express Scripts, which is based in north St. Louis County, is targeting $1.8 billion in additional savings for its clients next year, compared with $1.3 billion in 2016, Credit Suisse Group said in a note Tuesday. In all, 85 drugs were put on its excluded medicines list for 2017.

In addition to Victoza, other drugs that will be newly excluded in 2017 include Zyclara, a skin cream for actinic keratosis sold by Valeant Pharmaceuticals International Inc., Bristol-Myers Squibb Co.’s arthritis treatment Orencia, Eli Lilly and Co.’s new Taltz treatment for psoriasis and brands of gout drug colchicine sold by privately held Prasco Laboratories and West Ward Pharmaceuticals Corp.

The exclusion of Victoza from Express Scripts is a “small disappointment,” Michael Novod, an analyst at Nordea Markets in Copenhagen, wrote in a note to clients. Novo probably hasn’t been willing to provide a large enough discount, he said.

AstraZeneca’s Chief Executive Officer Pascal Soriot has signaled that pricing pressure for diabetes treatments in the U.S. had pushed his firm to shift its long-term bets toward cancer drugs instead. Less of the company’s $40 billion to $41 billion in projected sales by 2023 is likely to come from diabetes than originally forecast, he said.

“There is enormous price competition and we don’t do as well as we thought in the U.S. for diabetes,” Soriot said in an interview. “Potentially from a pipeline, from a clinical trial viewpoint, we may look better, but the price competition is strong.”

Novo’s basal insulins Novolin and NovoLog and and Sanofi’s Apidra also won’t be covered by Express Scripts in 2017, though the category will be reassessed later this year when new therapies are introduced, it said. Those treatments were rebuffed in favor of Humulin and Humalog, two blockbusters from Indianapolis-based Lilly.

The U.S. drugmaker’s “strong relationship” with the pharmacy benefits manager suggests that Lilly will probably win coverage for its Basaglar, a biosimilar — or cheaper copy — of Sanofi’s blockbuster Lantus insulin, when it’s launched in the U.S. at the end of the year, according to Jo Walton, an analyst at Credit Suisse.

That could be more bad news for both Novo Nordisk and Sanofi, as Basaglar’s entry into the market is likely to put further pressure on insulin prices.

Reuters contributed to this report.