As 2014 comes to a close, we should be thinking about what to expect for 2015. The start of a new year is a time for new challenges, new goals, and inevitably, a new prescription formulary.
What does this mean for you?
Express Scripts and Caremark have decided to remove certain asthma maintenance inhalers from their national preferred formulary and provided a list of covered alternatives. For more information and the full list of excluded drugs, see our post on the 2015 formulary changes.
What if my prescription is on the exclusion list?
- First, confirm whether Express Scripts, Caremark, or another PBM manages your pharmacy benefits. Many drugs that aren’t covered by one company are covered by the other.
- Next, check with your plan to be sure that your prescription won’t be covered. Not all plans use the national formulary, and yours may vary.
- If your prescription won’t be covered, it doesn’t hurt to try appealing. Ask your doctor to write a note, and ask your plan for information on how to appeal for coverage. This is more likely to work in cases where you’ve tried the other options and they don’t work for you, or there’s a medical reason why you aren’t able to take the covered alternative.
- Finally, get in touch with your doctor and explain that your current prescription will no longer be covered by your insurance in 2015. Show thm the list of preferred alternatives. You and your doctor can decide which alternative to try, or whether to explore other options for coverage.
So what are the changes for diabetes coverage in 2015?
Caremark 2015 Formulary Change
Reminder: in 2014, Caremark also removed Alvesco from their national formulary. Alvesco is also not a commonly used steroid inhaler for many patients, and the removal was fairly unremarkable. The suggested alternatives, in particular Flovent and Asmanex, are the most popular steroid inhalers dispensed at most pharmacies and would be great alternatives for patients who may have previously been on Aerospan or Alvesco.
Express Scripts 2015: No changes from the 2014 formulary
My main concern with last year’s change is the removal of one of the most popular and widely used steroid inhalers, Flovent. Most patients with asthma, especially children, use Flovent as a maintenance inhaler in conjunction with an albuterol rescue inhaler (Proair, Proventil, Ventolin). The alternatives Asmanex, Pulmicort, and QVAR are typically prescribed less often, however, once you’re transitioned they should provide similar anti-inflammatory action.
Asmanex, Pulmicort Flexhaler, and QVAR are covered on both formularies, and all have prescription savings cards or assistance programs. You can find additional savings for Asmanex here, Pulmicort here, and QVAR here.
Non-steroidal anti-inflammatory drugs (NSAIDs) are widely used for the treatment of acute pain and chronic inflammatory and degenerative joint diseases. The long term use of NSAIDS is restricted by the occurrence of upper gastrointestinal (GI) complications such as ulcers and bleeding.
Celebrex is a more selective NSAID which is marketed as having fewer GI side effects and similar effectiveness. Celebrex is more expensive and prescription-only, but is it better than ibuprofen (Motrin, Advil)? Let’s look.
- Which is better for pain?
Celebrex and ibuprofen have been compared in numerous studies for specific types of pain. Results swing both ways. Here are some examples: Celebrex was more effective for pain from ankle sprain, ibuprofen for dental pain, and both were equal for postoperative pain and treatment of acute gout attacks. I’d say it’s a wash and they both work just as well. It’s a draw for pain.
- What about the heart?
Long term use of NSAIDS carries a slightly increased risk of stroke and heart disease. The most frequently used NSAIDs in clinical practice like ibuprofen and Celebrex are associated with an increased risk of heart attack at high doses or in persons with diagnosed coronary heart disease. It’s a draw here for the heart, both carry small risks long term.
- What about gastrointestinal (GI) bleeding?
The use of any NSAID has been associated with a 3- to 5-fold increase in the risk of stomach irritation, ulcer or bleeding. However, Celebrex is associated with a lower risk of bleeding. There are some more differences to know: with ibuprofen the higher the dose, the higher the risk of GI bleed (200 mg = less risk, 600 mg = more risk), but the risk of GI bleed does not increase with higher doses of celecoxib. Winner = Celebrex
- What about the kidneys?
Serum creatinine and creatinine clearance, measures of kidney function, have been found to be significantly increased in patients treated with ibuprofen in comparison with celecoxib. This is important—Celebrex is safer on the kidneys. Winner = Celebrex
- What about the liver?
- What about the cost?
Cost is a huge difference between the two, but the patent for Celebrex (celecoxib) expires in December 2014 so a generic option should soon be available. That should drop the cost quite a bit. Winner = Ibuprofen
- Which is more convenient?
We get lots of questions from folks who don’t understand how GoodRx works. Over the next few months, we’ll provide a few true stories of Americans who are fighting to afford their health care, and some of the ways that GoodRx is being used to help.
Lauren counts herself lucky—she has a steady job at a large company, and her employer provides health insurance. There’s just one catch: the only plan offered by her company has a very high deductible of $3,500.
In insurance-speak, this is called a High Deductible Health Plan, or HDHP. In 2015, more than 25% of insured Americans will have HDHPs, which require you to spend at least $1,250 (or potentially much more) annually before your plan contributes. Employers like HDHPs as they save money for both the company and the employee. In 2015, many companies will offer an HDHP as the only plan option for their employees.
As a young, healthy woman, this means Lauren will pay all of her medical and prescription expenses out of her own pocket unless she has a major medical issue.
Lauren is aware of some ways to cut her prescription costs, and her doctor always prescribes generic medications when possible. Until recently, she was taking fluoxetine (generic Prozac), which she found at $4 from some pharmacies—lower than many insurance co-pays—and generic Adderall. Her total was around $50 – $60 per month; not cheap, but manageable.
Her doctor recommended GoodRx to help Lauren save when she made the switch, but for too long, Lauren paid the full $120, thinking GoodRx must be too good to be true.
Finally, fed up with paying so much for the generic medications that she needed on top of her insurance premium, she decided to give GoodRx a shot. She was shocked when a GoodRx coupon reduced her total to $60 for both prescriptions—a 50% savings.
Lauren will save $720 over the course of the year and continue to be able to afford the medication she needs.
If you’re on an HDHP, it’s always worth comparing GoodRx prices to your insurance co-pay. You’d be surprised how often GoodRx can find lower prices. Keep in mind that when you pay with a GoodRx discount, it will not count towards your deductible. It’s up to you to decide whether it makes more sense to pay less for your prescriptions now or try to get through your deductible phase to get your full co-pay benefits.
It’s a blessing to have effective meds to control nausea and vomiting from chemotherapy. Now we have an even better choice and this may be one of the best new meds of the year. Is it possible to transform the awful experience of chemo into one that’s better tolerated? Let’s hope.
Hot off the press is the approval of Akynzeo, a capsule for the prevention of nausea and vomiting from chemotherapy. Akynzeo is the first drug that is a combination of two meds that work differently: netupitant, an NK1 receptor antagonist, and palonosetron, a 5-HT3 receptor antagonist. Compared to palonosetron (Aloxi) alone, Akynzeo was significantly more effective and was generally well tolerated, and Aloxi has been the previous bad-ss in this category.
During the rollout of Akynzeo, which will likely be expensive, what are other options?
- Emend (aprepitant). Given in the days pre-chemotherapy (from day 1 to 3), Emend is an oral or intravenous medication that is expensive but works well to control nausea and vomiting.
- Dexamethasone given days 1 to 3 is a corticosteroid option you can get orally or through an IV. It’s cheap, has been around forever, and works well.
- 5-HT3 serotonin receptor antagonists have completely transformed the treatment of nausea and vomiting so you need to know this class of medications. Ondansetron (Zofran) is available as a generic so it is the cheapest of these medications. It comes in a dissolvable tablet or a pill. Palonosetron (Aloxi) is very expensive but works extremely well for nausea and vomiting from chemotherapy (though not as well as the new Akynzeo), but it’s good to have this drug as an option. Granisetron (Sancuso) is available as a patch, so you can avoid taking pills or receiving injections, but it’s expensive—really expensive.
Potassium chloride and potassium citrate—they’re both potassium so they should be the same, right? The names of these medications look nearly identical and can be extremely confusing, but you should know that these different forms of potassium treat different conditions and can’t be substituted for each other.
What does potassium chloride treat?
Potassium chloride is indicated for the treatment of hypokalemia also known as low potassium levels.
Low potassium levels may be due to diet, a side effect of medications, diarrhea and vomiting, sweating, or certain diseases.
What is the brand name for potassium chloride?
What does potassium citrate treat?
Potassium citrate is indicated for the treatment of kidney stones.
Kidney stones are crystal-like structures that form in the body usually as a result of excess amounts of uric acid or calcium. Kidney stone formation can be due to diet, certain diseases, genetics, or a side effect of medications.
What is the brand name of potassium citrate?
Potassium Chloride is available in 8 mEq, 10 mEq, 15 mEq, 20 mEq, 25 mEq, 40 mEq, and 50 mEq strengths, and in the following forms: tablet, capsule, effervescent tablet, powder packet, and liquid.
Potassium citrate is only available as a tablet, in 540 mg, 1080 mg, and 1620 mg (equivalent to 5 mEq, 10 mEq, and 15 mEq) strengths.