Alternatives to Doxycycline, A Common Drug With A Complicated Past

Katie Mui
Katie Mui is on the Research Team at GoodRx.
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Every year, insurance companies change their prescription drug coverage, adding and removing certain medications from formularies. Of the 80 drugs dropped from formularies in 2018 by Express Scripts and Caremark (two of the largest companies that manage pharmacy benefits for more than 200 million Americans), three are different versions of the same drug, doxycycline.

Which means that doxycycline, a commonly used antibiotic, is now a lot more expensive.

Doxycycline is often prescribed for a range of bacterial infections; it is the first-line therapy for tick-borne illnesses like Lyme disease and is often used to treat acne, UTIs, rosacea, and chlamydia.

Doxycycline 40 mg capsules are now on the Express Scripts national formulary exclusion list, with the preferred alternative being the brand version, Oracea. Brand name drugs Doryx and Monodox have been removed from Caremark’s Standard Control Formulary.

What does this mean?

One a drug is taken off the formulary, it is no longer covered by insurers working with that pharmacy benefit manager (in this case, Express Scripts or Caremark). If you’re prescribed one of these three doxycycline variations, you will find that the out-of-pocket cost is surprisingly high.

Drug name Average cash price
Doxycycline 40 mg capsules $660
Doryx $1,475
Monodox $617

I can’t afford that. What are my options?

First, the good news: There are two doxycycline generics – doxycycline hyclate and doxycycline monohydrate – and both are on the Express Scripts preferred list while doxycycline hyclate is on Caremark’s. Doxycycline hyclate and doxycycline monohydrate have the same active ingredient in different salt forms. They’re generally thought to work the same and have the same side effects.

The bad news: Each health plan designates drugs to different tiers, and that helps determine what your drug costs are with your insurance. Even though doxycycline hyclate and doxycycline monohydrate are “preferred” drugs, there is no guarantee that the medication at the dosage and form you’re prescribed will be on a low tier (Tier 1-2), which has the lowest co-pays.

In recent years, doxycycline been a case study in unseemly price hikes. In 2012, the price of doxycycline tablets went from 5.6 cents to $3.65 a pill in the span of a year. In 2013, its price increased 92.5% in 6 short months – just as there was a Lyme disease outbreak in Maine. Several drug manufacturers have been questioned about possible price-fixing schemes involving doxycycline in 2015 and as recent as 2017. The point is, doxycycline may still be expensive even if it’s covered by insurance.

What about the “preferred alternative” Oracea?

Express Scripts recommends physicians prescribe Oracea in place of its generic, doxycycline 40 mg capsules. Oracea is approved by the FDA to treat rosacea, and the 40 mg of the active ingredient is delivered in two steps: 30 mg immediate-release and 10 mg delayed-release. Since Oracea is a preferred brand name drug, it is likely to be on Tier 3 or higher, meaning it has an expensive co-pay.

Are there alternatives for doxycycline?

Luckily there are several alternatives for doxycycline. Here are some doctor recommended alternatives based on your medical condition.

Condition Drug name Lowest GoodRx price
Lyme disease, acne,
rosacea, UTI, STI
doxycycline monohydrate
doxycycline hyclate
Lyme disease amoxicillin $4
Lyme disease cefuroxime axetil $27.22
Acne, rosacea, UTI ,STI azithromycin $7.20
Acne, rosacea minocycline $72
Acne erythromycin $9.99

Lyme disease:
Even though doxycycline is the #1 treatment for early Lyme disease, amoxicillin (Amoxil) and cefuroxime axetil (Ceftin) were shown in clinical trials to work just as well.

Acne: Doxycycline is often prescribed for inflammatory acne but side effects include tooth discoloration, nausea, and photosensitivity. Oral meds minocycline (Minocin) and azithromycin (Zithromax), and topical gel erythromycin (Ilotycin) are also common antibiotics for acne.

Rosacea: An oral medication is usually only prescribed if lifestyle changes and topical medications are not enough to treat a stubborn flare-up. Most drugs in the tetracycline antibiotics family can help with rosacea, but like doxycycline, they can be expensive. Azithromycin is an affordable alternative.

UTIs: Your doctor will prescribe you an antibiotic depending on the type of bacteria found in your urine. Sulfamethoxazole-trimethoprim (Bactrim)nitrofurantoin (Macrobid), and cephalexin (Keftab) are all effective for simple UTIs. Doxycycline or azithromycin may be used if the E. coli or Strep faecalis bacteria is resistant to first-line treatments and symptoms continue.

STIs: Doxycycline and azithromycin are first-line medications for chlamydia. The CDC also recommends either doxycycline or azithromycin along with antibiotic ceftriaxone (which comes as an injection) to treat uncomplicated gonorrhea.

How do I save on doxycycline?

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