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Dropped by Insurance: Changes for Diabetes in 2015

by Roni Shye on September 15, 2014 at 3:04 pm

As 2014 comes to a close, we should be thinking about what to expect for 2015. The start of a new year is a time for new challenges, new goals, and inevitably, a new prescription formulary.

What does this mean for you?

Express Scripts and Caremark have decided to remove certain diabetes medications from their national preferred formulary and provided a list of covered alternatives. For more information and the full list of excluded drugs, see our post on the 2015 formulary changes.

You can also find the list of changes for Express Scripts members here, and for Caremark members here.

What if my prescription is on the exclusion list?

  • First, confirm whether Express Scripts, Caremark, or another PBM manages your pharmacy benefits. Many drugs that aren’t covered by one company are covered by the other.
  • Next, check with your plan to be sure that your prescription won’t be covered. Not all plans use the national formulary, and yours may vary.
  • If your prescription won’t be covered, it doesn’t hurt to try appealing. Ask your doctor to write a note, and ask your plan for information on how to appeal for coverage. This is more likely to work in cases where you’ve tried the other options and they don’t work for you, or there’s a medical reason why you aren’t able to take the covered alternative.
  • Finally, get in touch with your doctor and explain that your current prescription will no longer be covered by your insurance in 2015. Show thm the list of preferred alternatives. You and your doctor can decide which alternative to try, or whether to explore other options for coverage.

So what are the changes for diabetes coverage in 2015?
Caremark 2015 Formulary Change
Removed medication: Accu-Chek testing   ||   Suggested alternative: OneTouch testing

Good news here—the suggested alternative OneTouch is the main brand of glucometer kit and test strips I see dispensed and preferred by a lot of pharmacies. OneTouch is often dispensed your doctor doesn’t specify and just writes a prescription for “glucometer and strips” due to the reliability and familiarity of pharmacists with Lifescan’s OneTouch products.

However, Accu-Chek glucometers and strips from Roche Diagnostics are not only popular, but were preferred on Caremark’s formulary last year along with OneTouch.

The problem with removing Accu-Chek from the 2015 formulary? A lot of patients have a hard time embracing change. The One Touch glucometer and strips are basic and easy to learn though, which is an advantage. If you need help or just a refresher on how to use OneTouch meters and strips, Lifescan offers support that can be accessed here.

Reminder: in 2014, Caremark also removed ALL Humalog and Humlin insulins from their national formulary (with the exception of Humulin U-500). The suggested alternatives are Apidra, Novolog, and Novolin insulins. I see more patients on Humalog rather than Novolog, though both work the same way in the body. Questions about conversions between the different types of insulin? Check out these links for help: part one and part two.

Express Scripts 2015 Formulary Change
Removed medication: Tanzeum   ||   Suggested alternatives: Byetta or Bydureon

The only difference this year is that the recently approved Tanzeum injection is excluded. Tanzeum was approved by the FDA on April 15, 2014 as a once-weekly injection similar to Bydureon. I do not think the exclusion of Tanzeum will affect many patients, especially since it is newly approved and Bydureon, a suggested alternative, is a comparable once-weekly option.

Reminder: in 2014, Express Scripts also removed Victoza from their national formulary. Victoza has been gaining a lot of popularity in the diabetic community and among prescribers. More patients are using Victoza injections than the covered alternatives Byetta or Bydureon. Victoza is unique because it is a once daily injection rather than twice daily like Byetta. One positive though—Bydureon, the other alternative, is only injected once weekly.

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