Americans, get ready for sticker shock at the pharmacy.
In 2017, the nation’s largest insurance companies will likely exclude up to 154 different drugs from coverage. If you’re taking one of these prescriptions, your co-pay is about to go way, way up.
Last year, popular drugs including Viagra and Qsymia were dropped by major insurance plans for 2016. The trend continues this year. Almost 50 popular brand-name and generic drugs will likely no longer be covered by one of the nation’s largest prescription insurance providers.
Who’s removing these drugs? Express Scripts and Caremark, companies that handle pharmacy benefits for more than 200 million Americans, are once again removing drugs from their national preferred formularies. Other pharmacy benefit managers will likely announce similar restrictions in the coming weeks.
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 create a formulary—a list of drugs they will cover—in conjunction with employers and health plans.
What does this change mean for you?
The newly excluded drugs fall into a couple major categories:
Several are brand-name drugs that may have a less expensive brand or generic alternative available.
Some drugs work in the same way as similar, cheaper drugs on the market, so only one is preferred by your insurance.
If your benefits are provided by Express Scripts or Caremark, you will pay the full cash price at the pharmacy for these excluded drugs in 2017. (On GoodRx, you can see estimated cash prices in grey next to most discount prices.)
If your coverage is changing, talk to your doctor to see if one of the covered alternatives might work for you. If you can’t switch, use GoodRx to find discounts or find patient assistance programs to help cover the cost. You may also be able to appeal the coverage with your insurance provider, with your doctor’s help.
Which drugs are affected?
Caremark in particular is making some major changes for 2016, which fall under three general categories: “hyperinflation” drugs (drugs that have had recent drastic price increases), new biosimilar alternatives, and stricter restrictions on expensive cancer and hepatitis C medications.
Hyperinflation. Caremark has identified some drugs that have had huge price increases, and excluded a selection that have similar alternatives in the same class of medications. One example is Alcortin A, which saw a 30-fold price hike over the past three years.
Biosimilars. You may have heard news over the past year or so about “biosimilars”—basically, generic medications for some specialty or biologic medications like insulin. (For more background on biosimilars, see our post here.)
Notably, Caremark will no longer cover Lantus, one of the most popular insulin brands.
Caremark is the first provider to restrict brand name drugs like Neupogen or Lantus that have (or will have) biosimilars available next year. They are suggesting Zarxio in place of Neupogen, and Basaglar in place of Lantus.
Expensive specialty medications. Caremark is also breaking ground by being the first provider to restrict coverage on brand name cancer treatments.
How can I make sure I pick a plan that will cover my drug?
Both Express Scripts and Caremark have made some fairly big changes in coverage over the past few years, and the overlap on many of the excluded drugs is shrinking. If you’re trying to choose a new plan, or switch based on coverage of a particular drug, it’s always a good idea to review the latest formularies before deciding.
Below, you can find all of the new removals from both formularies in 2017. For a full list of all 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.
If you have a choice though, Caremark will be far more restrictive in 2017. They are excluding about 40 new drugs, for a total of around 130. Express Scripts, in contrast, is only restricting 5 new drugs in 2017, for a total of about 85 that they will not cover.
New Exclusions for 2017
Alcortin A (Caremark)
All non-BD pen needles and syringes (Caremark)
butalbital/acetaminophen/caffeine capsules (Caremark)
Carnitor SF (Caremark)
Colchicine (Express Scripts)
Effexor XR (Caremark)
Fioricet capsules (Caremark)
Helixate FS (Caremark)
Kineret (Express Scripts)
Klor-Con packets (Caremark)
Millipred DP (Caremark)
Orencia (Express Scripts)
Proventil HFA (Caremark)
Taltz (Express Scripts)
venlafaxine ER (except tablet) (Caremark)
Ventolin HFA (Caremark)
Zebutal capsules (Caremark)
Zyclara (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 also have different coverage. This means different drugs may be covered or excluded on your plan if you have coverage through work, for example. Please get in touch with your insurance provider if you have any questions about your coverage.
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