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 set a national preferred formulary, and also work with employers and health plans to develop more individualized formularies (though it is your benefit provider—your health plan—that ultimately decides which formulary to offer).
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.
EDIT 9/2/14: For greater accuracy, the final sentence in the second paragraph above has been updated. The previous text read: “They also set the formulary for everyone under their prescription drug benefit.”