Express Scripts and Caremark have removed certain medications from their formulary starting in January 2014. These companies handle prescription benefits for more than 200 million Americans, so your prescription coverage will likely be changing in the new year.
We’re reviewing which prescriptions will no longer be covered and the suggested alternatives to give you a better picture of your options. Listed below are some changes to the coverage of steroid nasal sprays for allergy symptoms from each formulary that might affect you:
Caremark and Express Scripts
I see a lot of patients using Veramyst, however, the alternatives all seem to be good choices—in particular fluticasone propionate (generic Flonase). Veramyst is very similar to Flonase so I don’t think patients will have issues converting.
The coverage on both formularies is almost identical in this category, with the exception of Qnasl, which is covered by Caremark but NOT by Express Scripts.
If you’re taking one of the removed drugs, what should your next steps be?
• Find out which company handles your prescription coverage. You can often check online, or call the number on your insurance card for more information.
• Double check the exclusion list to review the removed medications and alternatives: Express Scripts and Caremark.
• If your prescription won’t be covered next year, contact your doctor or healthcare provider and explain that your pharmacy coverage has changed and that there is a suggested alternative for your current medication.
• You and your doctor can then decide which alternative to try, or whether to explore other options for coverage.
What if you can’t / don’t want to switch to the covered alternative?
Particularly for specialty pharmacy prescriptions, there are assistance programs out there that may be able to help if your prescription is no longer covered by your insurance plan, and switching isn’t an option for you. Organizations like the Partnership for Patient Assistance and NeedyMeds can help you find which programs you’re eligible for.
Check the official website for your medication. In addition to prescription savings cards, the manufacturer will often offer a patient assistance program. You must meet income requirements or be uninsured for some programs, but others can help if you don’t have coverage for a particular drug.
If all else fails, it never hurts to ask to see if your prescription can still be covered. Have your doctor write a note, plead your case, make some noise – we’ve heard about coverage exceptions for some patients.
One last option: if you’re able to change your insurance plan, many of the drugs excluded by Express Scripts are covered by Caremark and vice versa. If you can find a plan that works for you with the prescription benefit offered by a different company, you may be able to keep your coverage.
The GoodRx Pharmacist