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Dropped by Insurance: Changes for Ear, Nose, and Throat Meds in 2015

by The GoodRx Pharmacist on September 29, 2014 at 12:39 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 ear, nose, and throat (ENT) drugs for allergies and ear infections from their national preferred formulary and have 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 ENT coverage in 2015?

Caremark 2015: No changes from the 2014 formulary

Reminder: as of 2014, excluded nasal sprays included Veramyst, Beconase AQ, Omnaris, Qnasl, Rhinocort Aqua, and Zetonna. The suggested alternatives are flunisolide, fluticasone propionate, triamcinolone, and Nasonex.

I see a lot of patients using Veramyst, but the alternatives all seem to be good choices—in particular fluticasone propionate (generic Flonase). Veramyst is very similar to generic Flonase so you shouldn’t have issues converting. Nasonex also has a savings card available from the manufacturer.

Express Scripts 2015 Formulary Change
Removed medication: Cetraxal   ||   Suggested alternatives: ciprofloxacin, Ciprodex

I am not concerned here—I don’t think that the removal of Cetraxal from the 2015 formulary will cause many problems.  Cetraxal is also available as generic ciprofloxacin 0.2% otic solution which is one of the suggested alternatives. Beyond that, however, both brand name Cetraxal and generic ciprofloxacin 0.2% are not often prescribed for ear infections due to their unpopular strength. Ciprodex, the other suggested alternative, is much more commonly used and prescribed. Ciprodex is a combination of the same antibiotic ciprofloxacin, and dexamethasone, a steroid, to help with inflammation.

Reminder: Express Scripts also doesn’t cover most brand name nasal sprays for allergies. Their suggested alternatives are also flunisolide, fluticasone propionate, triamcinolone, and Nasonex—the only real difference here is that Express Scripts offers coverage for Qnasl where Caremark doesn’t. Again, generic fluticasone propionate and Nasonex are good alternatives, and you shouldn’t have trouble switching if necessary.

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