For many Americans with health insurance, more than 40 popular brand-name drugs may no longer be covered starting in January 2015. Express Scripts and Caremark, companies that handle pharmacy benefits for more than 200 million Americans, are removing over 40 drugs from their formularies at the end of 2014. This is in addition to the more than 50 drugs removed last year.
What are Express Scripts and Caremark?
Express Scripts and Caremark are companies that administer prescription drug benefits for many health insurance companies and Tricare. While you may have health insurance from Anthem, Aetna or another insurer, your pharmacy benefits are usually handled by these companies or their competitors. They also set the formulary for everyone under their prescription drug benefit.
What does this change mean for you?
The drugs listed below are, for the most part, brand names for which there may be a less expensive brand or generic alternative available. If your benefits are provided by Express Scripts or Caremark, you will pay the full cash price at the pharmacy for these brands in 2015. (You can see estimated cash prices on GoodRx by clicking on a pharmacy name after you look up a drug.)
If your coverage is changing, talk to your doctor to see if a covered alternative might work for you. If you can’t switch, you may be able to use GoodRx or find patient assistance programs to help cover the cost.
Which drugs are affected?
Under Express Scripts, several arthritis, pain, and testosterone replacement drugs will no longer be covered, along with others for diabetes, acne, and migraine. Some of the most notable drugs that will no longer be covered include: Vimovo and Duexis for arthritis pain; pain med Zohydro ER; diabetes injectable Tanzeum; Axert and Frova for migraine; and several viscosupplement injections for osteoarthritis like Hyalgan and Euflexxa.
Caremark has also made significant changes over the past couple of years, and is adding more exclusions in 2015. There is very little overlap with Express Scripts on the newly excluded drugs, so if you are choosing a new plan based on coverage of a particular medication, you may want to consider reviewing the formularies before deciding.
See the excluded medications below. For a full list of excluded drugs and covered alternatives, see the Express Scripts list here and the Caremark list here. If you’re not sure which company provides your pharmacy benefit, contact your insurance company.
2015 Excluded Drugs
Accu-Chek test strips and kits (Caremark)
All non-OneTouch strips and kits (Caremark)
Adderall XR (Caremark)
Aerospan HFA (Caremark)
Apexicon E (Caremark)
Aranesp (Express Scripts)
Axert (Express Scripts)
Benzaclin gel pump (Express Scripts)
Cetraxal (Express Scripts)
Epogen (Express Scripts)
Fentora (Express Scripts)
Frova (Express Scripts)
Gel-One (Express Scripts)
Hyalgan (Express Scripts)
Incivek (Express Scripts)
Pancreaze (Express Scripts)
Pertyze (Express Scripts)
Proventil HFA (Caremark)
Stendra (Express Scripts)
Subsys (Express Scripts)
Supartz (Express Scripts)
Tanzeum (Express Scripts)
testosterone gel (both)
Ultresa (Express Scripts)
Veltin (Express Scripts)
Zohydro ER (Express Scripts)
An important note about Medicare and individual plans:
These changes DO NOT apply to Medicare plans; if your Medicare benefit is managed by Express Scripts, you should check your coverage with your pharmacist or online through the Medicare.gov portal.
Some individual private insurance plans managed by Express Scripts or Caremark may have different formulary coverage, meaning different drugs may be covered or excluded. Please check with your plan if you have any questions or concerns.
Effective Friday, August 15, 2014, Namenda (memantine) 5 mg and 10 mg tablets have been discontinued. According to the manufacturer, Forest Laboratories, the discontinuation is not for safety reasons, but because the company is going to be focusing on their once-daily Namenda XR (memantine) capsules.
What strengths and forms of Namenda XR are still available?
Namenda XR is available as a once-daily capsule in 7 mg, 14 mg, 21 mg, and 28 mg dosages.
Will Namenda oral solution still be available?
Yes. Forest Laboratories will continue to make Namenda 2 mg/ml oral solution along with the XR capsules.
How do I switch from the tablets to the XR capsules?
- If you are currently taking the Namenda 5 mg tablet twice daily your dosage would change to the Namenda XR 14 mg capsule once-daily.
- If you are currently taking the Namenda 10 mg tablet twice daily your dosage would change to the Namenda XR 28 mg capsule once-daily.
Are there any advantages to using the Namenda XR capsules?
Yes. First, Namenda XR capsules are taken once-daily. Once-daily dosing usually means that you are more likely to use the medication.
The second advantage is that the Namenda XR capsules can be opened and sprinkled on applesauce for ease of administration. If you have difficulty swallowing pills these XR capsules would be beneficial.
The bad news?
Hemorrhoids are common cause of bright red bleeding from the rectum and something you will often be managing from home. Know that some experts recommend colonoscopy for all patients older than 40 years who have hemorrhoidal symptoms and rectal bleeding, but if that’s been done or your doctor is sure it’s just hemorrhoids, what works?
1. Fiber supplementation. Using Psyllium or unprocessed bran has been shown in studies to decrease bleeding, pain, prolapse and itching from hemorrhoids. This is because fiber helps you have soft bulky stools that can be passed without straining. Do this, no matter what.
2. Over the counter topical hemorrhoid medications come as nonprescription topical preparations you know well, like preparation H. Some contain steroids (Anusol HC), anesthetics, and astringents (witch hazel) and are recommended for hemorrhoidal disease. It may surprise you to know that no randomized studies support their use. Steroid-containing creams should not be used for prolonged periods because of their effects on skin.
3. Sitz baths. A sitz bath is a warm, shallow bath (you can put medications in it if you want) that you sit in and the water covers only your hips and buttock. Sitz baths are commonly recommended for hemorrhoids but guess what, a review of studies found no benefit for hemorrhoids so maybe don’t waste your time.
3. Nifedipine ointment (a prescription, made by a compounding pharmacy) and lidocaine cream work for hemorrhoids that are thrombosed, meaning a clot has formed inside the hemorrhoid. These are exquisitely painful and nifedipine ointment plus Xylocaine (lidocaine) is more effective for pain relief than either alone.
4. Surgery. The most common surgical treatments are rubber band ligation and excisional hemorrhoidectomy (cutting it out). A review comparing excisional hemorrhoidectomy to rubber band ligation showed that ligation resulted in less postoperative pain and allowed patients to return to work and to their previous level of functioning faster. For patients with severe hemorrhoids though, excisional hemorrhoidectomy has less chance of recurrence.
Remember—effective Monday, August 18, 2014, tramadol (Ultram) and any products that contain tramadol, including Ultracet (tramadol/acetaminophen), Ultram ER (tramadol ER), or Conzip, will be considered schedule IV substances.
This means ANY medications containing tramadol will now have stricter rules for dispensing. This may affect your current prescription as well as your future prescriptions if you regularly take these medications.
What is a schedule IV narcotic?
According to the Drug Enforcement Agency (DEA), schedule IV drugs, substances, or chemicals are defined as drugs with a low potential for abuse and low risk of dependence.
You can find more information on the various drug schedules here.
Was tramadol scheduled before?
How will I know if my prescription is affected?
If your current prescription was written with more than 5 refills—you will be affected. Tramadol prescriptions will now be allowed only 5 refills, for a total of 6 fills.
If your current prescription was written more than 6 months ago—you will be affected. Tramadol prescriptions are only good to be filled at your pharmacy for 6 months after the date they are written by your doctor.
Once 6 months has passed from the written date, whether you’ve filled your prescription and any refills or not, it is considered expired. Once it is expired, a new prescription will need to be issued by your doctor.
What are other examples of schedule IV prescriptions?
These other medications are also considered schedule IV and have the same rules applied to them:
Synthroid, one of the most commonly prescribed brand name medications in the U.S., often requires lifelong treatment for hypothyroidism. For a medication that you may be paying a little more for and is a lifetime commitment, here are some lesser known points about Synthroid.
1. What is it?
Synthetic thyroxine (T4) comes as Synthroid or the generic levothyroxine. T4 is what is known as a prohormone that is deiodinated in our tissues to form T3, the active thyroid hormone. There is an advantage to taking the prohormone T4 which is that your own physiologic mechanisms control the production of active hormone (T3).
There has been considerable controversy about their bioequivalence. Because there may be subtle differences in bioavailability between Synthroid and levothyroxine, it is preferable to stay with one formulation when possible. The American Thyroid Association and The Endocrine Society recommend that patients remain on the brand Synthroid if that was initially prescribed. If you are on generic levothyroxine try and stay with the same generic manufacturer; your pharmacy can help you with that.
3. What’s the right dose of Synthroid to start on?
The average replacement dose of T4 in adults is approximately 1.6 mcg/kg per day which would be 112 mcg per day in a 70-kg adult, but this is not a one-size-fits-all recommendation.
4. How do I take it? This matters.
Synthroid should be taken on an empty stomach, ideally an hour before breakfast. Another option is to take it at bedtime if you’ve had nothing to eat for several hours. Synthroid or levothyroxine should not be taken with other medications that interfere with their absorption, such as iron or calcium supplements or proton pump inhibitors (omeprazole, Nexium, etc).
5. What blood tests for monitoring do I need?
Patients who are treated with T4 usually begin to improve within two weeks, but complete recovery can take several months. Although symptoms may begin to resolve after two to three weeks, steady-state TSH (thyroid stimulating hormone) concentrations are not achieved for at least six weeks. A TSH blood test should be measured six weeks after starting. Once the values of TSH in patients with primary hypothyroidism return to the reference range, periodic monitoring is warranted.
6. What is my goal TSH on Synthroid?
Yes there is plenty of controversy here, so try to rely on science. Most laboratories have used values of a normal TSH to be less than 4.5 to 5.0 mU/L but some argue that the upper limit of normal range should be reduced to 2.5 mU/L. This is because most “normal thyroid” volunteers have TSH blood values between 0.4 and 2.5 mU/L. The aim should be to keep TSH within the normal reference range (approximately 0.5 to 5.0 mU/L) but if you continue to have hypothyroid symptoms, it is reasonable to talk to your doc to increase the dose of Synthroid, and aim for a serum TSH value in the lower half of the normal range (0.4-2.5).
7. I’m on too much Synthroid but I don’t mind the weight loss and how I feel, is that ok?
Overreplacement (taking too much Synthroid so your TSH is too low) is a bad idea and I see it all the time. The main risk is atrial fibrillation, which occurs three times more often in patients who are on too much Synthroid replacement. You may also have accelerated bone loss (and thus fractures).
8. Do I need just Synthroid (T4) or do I need combination T4 and T3 therapy?
Again, another area of controversy. Here is what the science shows. Some folks remain symptomatic in spite of Synthroid or levothyroxine replacement and having normal serum TSH concentrations. In fact, in people taking Synthroid and with normal TSH values, 9-13% more still report impaired psychological well being compared to “normal thyroid” people. Years of studies have been done to see if people benefit from a combination of T3 (Cytomel) and T4 instead of just T4 (Synthroid) and almost all studies show that combination T4-T3 therapy does not appear to be superior to Synthroid monotherapy for the management of fatigue, bodily pain, anxiety, depression or quality of life.
Again, many studies have compared Synthroid to desiccated thyroid extract and revealed no differences in symptoms and neurocognitive measurements between the two groups.
10. What messes with my Synthroid?
Many things can. Women taking estrogen therapy may need more Synthroid so a TSH blood test should be checked 12 weeks after starting estrogen therapy. A high-fiber diet can interfere with the absorption of Synthroid, and know that coffee reduces the absorption of Synthroid by about 30 percent.
So there’s that.