Dropped by Insurance: In 2014, Will Your Arthritis and Transplant Drugs Be Covered?

Roni Shye
Roni Shye, PharmD BCGP BCACP, is a licensed pharmacist in the states of Florida, Ohio, and Pennsylvania.
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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.

Over the next couple of weeks, we’ll be reviewing which prescriptions will no longer be covered and the suggested alternatives to give you a better picture of your options. To begin with, let’s take a look at the specialty pharmacy meds removed from each formulary.


Removed medication: Hecoria   ||   Suggested Alternative: tacrolimus

Some transplant programs favor Hecoria over tacrolimus.  With Hecoria, doctors are able to control which version of tacrolimus their transplant patient receives each fill. It is important to receive the same exact manufacturer with each refill for transplant patients due to the possibility of organ rejection. I typically see more patients taking tacrolimus from a specific manufacturer; however, doctors at various institutions (such as University Hospital in Cleveland, Ohio) prescribe Hecoria as a part of their transplant medication regimen.

Express Scripts

Removed medications: Cimzia, Simponi, Stelara,  Xeljanz   ||   Suggested Alternatives: Enbrel or Humira

I am concerned with the removal of Simponi because it’s a once-a-month injection. This once-monthly injection is great for compliance for patients that have a hard time remembering to use their medication, whereas the covered alternatives (Enbrel or Humira) are 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, but it can greatly impact patients with arthritis. Patients with arthritis, specifically in the hands and fingers, may already have problems CC by Christian Cwith injection technique so a change in their dosing regimen can impact them greatly.

I am also concerned with Xeljanz being removed from the list since it is the first medication in a new class of oral drugs used to treat arthritis. Many patients do not like to inject themselves and Xeljanz was their answer. The alternatives, Enbrel and Humira, are both only available as injectables. Humira and Enbrel are great, effective alternatives though, and both of them have prescription savings cards available from the manufacturers: you can find the Enbrel savings card here and the Humira savings card here.

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

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