Dropped by Insurance: Will Your Pain Prescriptions Be Covered in 2014?

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

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 pain med coverage from each formulary that might affect you:


Removed medication: Flector patches   ||   Suggested Alternative: diclofenac, meloxicam, or naproxen

The convenient Flector patch will be an excluded medication as of 2014. Unfortunately, none of the formulary alternatives are available in patch form. I have seen an increase in the use of Flector patches, especially among pain management doctors and the elderly population due to its indication for post-herpetic neuralgia AKA pain from shingles. A lot of patients have issues with compliance and remembering to take pills or applying gels throughout the day so patches are great for those individuals. Patches are perfect for patients with arthritis due to the ease of application and administration. The removal of Flector Patches from the formulary may unintentionally cause an increase in the prescribing of lidocaine patches for the same reasons I have listed above.

Express Scripts

Removed medications: Avinza, ExalgoKadian   ||   Suggested Alternatives: morphine ER, oxymorphone ER, Opana ERNucynta EROxycontin
Kadian is the concern here—it’s a long-acting morphine, but in capsule form where the covered alternatives are only available in tablet form. This can be problematic because the long-acting opioids cannot be crushed or chewed due to their long-acting ability and this is where a capsule dosage form like Kadian plays a role. The capsules can be opened and sprinkled onto applesauce and then swallowed. This is important for patients who may have issues swallowing tablets—which believe it or not affects a lot of patients.

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

Drugs featured in this story

Filed under