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50+ Drugs Dropped by Insurance in 2016, Including Viagra and Qsymia

by Elizabeth Davis on August 12, 2015 at 12:38 pm

It’s that time again—the new lists of covered and excluded drugs on next year’s insurance plans are out, and it doesn’t look great. For many Americans with health insurance, more than 50 popular brand-name and generic drugs may no longer be covered starting in January 2016.

Express Scripts and Caremark, companies that handles pharmacy benefits for more than 200 million Americans, are removing about 20 – 30 drugs each from their national preferred formularies at the end of 2015.

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 fall into a few main categories. Many are brand-name drugs that may have a less expensive brand or generic alternative available. There may also be multiple similar drugs on the market, but 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 2016. (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 one of the covered alternatives 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. You may also be able to appeal the coverage with your insurance provider, with your doctor’s help.

Which drugs are affected?

Notably, Caremark will no longer cover erectile dysfunction med Viagra. With Levitra already on their exclusion list, that means Cialis is now your only option with Caremark. Weight loss med Qsymia will no longer be covered by either formulary. Express Scripts only offers generic phentermine as an alternative, while Caremark may still cover some newer options like Belviq, Contrave, and Saxenda. And now that generic Abilify (aripiprazole) is available, brand-name Abilify will no longer be covered on Caremark plans.

The new hepatitis C drugs also have some coverage changes. For example, Express Scripts is now excluding all of the new, expensive treatments except Viekira Pak—however, they have a conditional exception for Sovaldi, which may be covered for certain types of hepatitis C with a coverage review.

Both PBMs have made some fairly big changes in coverage over the past few years, and there is very little overlap on many of the excluded drugs. 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 new formularies before deciding.

Below, you can find all of the new removals from both formularies in 2016. 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.

New Exclusions for 2016

Abilify (Caremark)
Acuvail (Express Scripts)
Alvesco (Express Scripts)
Amitiza (Caremark)
Arnuity Ellipta (Express Scripts)
Asacol HD (Express Scripts)
Avonex (Caremark)
Bydureon (Caremark)
Carac (Caremark)
Cardizem (Caremark)
Cardizem CD (Caremark)
Cardizem LA and generics (Caremark)
clobetasol spray (Caremark)
Clobex spray (Caremark)
Cymbalta (Caremark)
Delzicol (Express Scripts)
Diovan (Caremark)
Dipentum (Express Scripts)
Doxycycline 40mg caps (Express Scripts)
Endometrin (Express Scripts)
Estrogel (Express Scripts)
Exforge (Caremark)
Exforge HCT (Caremark)
Extavia (Caremark)
fluorouracil 0.5% cream (both)
Fortesta (Caremark)
Fosrenol (Caremark)
Ganirelix (Express Scripts)
Harvoni (Express Scripts)
Incruse Ellipta (Caremark)
Intuniv (Caremark)
Invokamet (Caremark)
Invokana (Caremark)
Istalol (Express Scripts)
Kombiglyze XR (Express Scripts)
Matzim LA (Caremark)
Mircera (Express Scripts)
Monovisc (Caremark)
Natesto (Express Scripts)
Noritate (Caremark)
Olysio (Express Scripts)
Onglyza (Express Scripts)
Plegridy (Caremark)
Qsymia (both)
Relistor (Caremark)
Ribasphere (RibaPak) (Express Scripts)
Ribasphere (RibaTab) (Express Scripts)
Sovaldi (Express Scripts)
Synvisc (Express Scripts)
Synvisc One (Express Scripts)
Valcyte (Caremark)
Viagra (Caremark)
Zomacton (Express Scripts)
Zubsolv (Caremark)

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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