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. There have been some big changes to the coverage on diabetes meds removed from each formulary, particularly when it comes to insulin:
The Caremark exclusions here include Humalog, Humalog 50/50, Humalog 75/25, Humulin N, Humulin R, and Humulin 70/30 (but not Humulin U-500). I see more patients on Humalog than Novolog, however, both work on the body the same way, either rapid acting or a combination of rapid/intermediate acting.
The main concern patients may have is “will my dose be the same?” The answer to that question is YES—the conversion from Humalog to Novolog and Humulin to Novolin is a 1:1 conversion. Therefore, if you using 10 units of Humalog you will also use 10 units of Novolog and the same applies for Humulin and Novolin. Apidra conversion is also 1:1, so once again your insulin dose will not change. These links from Group Health Cooperative and The Pharmacist Letter (via Albany.edu) will be very helpful for any questions about conversion: Part 1 and Part 2
Novolog and Apidra also have manufacturer discounts available—you can find the Novolog program here and the Apidra program here.
Removed medications: Victoza || Suggested Alternatives: Byetta or Bydureon
Victoza has been gaining a lot of popularity in the diabetic community and among the prescribing doctors, including endocrinologists. A majority of patients are using Victoza injections compared to the covered alternatives of Byetta or Bydureon. Victoza is unique because it is a once daily injection rather than twice daily like its suggested alternative Byetta. However one positive is that Bydureon, the other alternative, is once weekly. Byetta, Bydureon, and Victoza all have manufacturer discounts available—you can find the Byetta program here, the Bydureon program here, and the Victoza program here.
Express Scripts will be covering Humalog and Humulin insulins (the same ones Caremark is dropping), and instead removing coverage for Apidra, Novolog, Novolog 70/30, Novolin N, Novolin R, and Novolin 70/30. The same conversions listed above apply 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 (like the insulins mentioned here). 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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