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Dropped by Insurance? Coverage Improves Instead for Inflammatory Conditions

by Roni Shye on September 19, 2014 at 11:01 am

A 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 has actually decided to add a medication back to their national preferred formulary. When it comes to drugs that treat inflammatory conditions like arthritis, psoriasis, and ulcerative colitis, you’ll actually have another option this year. They have still provided a list of covered alternatives as well.

If your benefit is provided by Caremark, you should also have nothing to worry about—there haven’t been any changes in coverage in this category for 2015, and Caremark did not specifically exclude any of these drugs last year.

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 Express Scripts changes for inflammatory conditions in 2015?
Added medication: Stelara  ||   Already excluded medications: Cimzia, Simponi, Xeljanz
Other suggested alternatives: Enbrel, Humira

Everything remains the same this year except for the addition of Stelara back onto the covered alternatives list. Having Stelara as an additional option is great news, especially for a patient who may have tried and failed with both Enbrel and Humira. Stelara has the advantage of being a maintenance dose given only every 12 weeks. The 3 month dosing interval of Stelara may be helpful for patients who don’t like to inject weekly or every other week, like with Enbrel or Humira.

What about the 2014 exclusions? I am mainly concerned with the exclusion of Simponi because it is a once a month injection, though the inclusion of Stelara may offset this in some cases. Simponi once monthly is great for compliance and for anyone who has a hard time remembering to use their medication, where the covered alternatives (Enbrel or Humira) are taken once a week or once every other week. The change from once monthly to once weekly (or even once every other week) may not seem like a big difference to a bystander, but it have a big impact. Patients with arthritis, specifically in the hands and fingers, may already have problems with injection technique so a change in their dosing regimen can make a huge difference.

I am also concerned with the exclusion of Xeljanz since it is the first medication in a new class of oral drugs used to treat arthritis. This is particularly concerning because a lot of patients do not like to inject themselves and Xeljanz was their answer. The alternatives, Enbrel and Humira, are both only available as injectables.

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