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Dropped by Insurance: Will Your Rescue Inhaler be Covered in 2015?

by The GoodRx Pharmacist on October 15, 2014 at 11:52 am

As 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 and Caremark have decided to make changes to the asthma rescue inhalers covered on their national preferred formularies, and have provided a list of covered alternatives. 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 changes for short-acting inhaler coverage in 2015?

Express Scripts 2015: No changes from the 2014 formulary
Reminder: as of 2014, excluded rescue inhalers included Maxair Autohaler, Proventil HFA, and Xopenex HFA. The suggested alternatives are Proair HFA and Ventolin HFA.

In my opinion, the excluded inhalers shouldn’t cause too many problems due to the similarities of the suggested alternatives.

My only concern is that Xopenex HFA is not on the formulary. Xopenex is an alternative for patients who experience unwanted side effects such as increased heart rate from the albuterol inhalers (Ventolin HFA, Proair HFA, and Proventil HFA). Removing Xopenex HFA from the formulary leaves patients who have tried albuterol inhalers without success with no appropriate alternative.

The exclusion of Maxair is no surprise though. It was phased out as of December 31, 2013 as part of the discontinuation of all inhalers that used CFCs. For more information, see this article from the FDA.

Caremark 2015 Formulary Change

Removed medication: Proventil HFA   ||   Suggested alternatives: Proair HFA

The main difference from the 2014 formulary is that Proventil HFA will no longer be covered, but the alternative Proair HFA should allow for an easy transition. There may be some confusion at first—the Proair HFA inhaler may look different—but it is another rescue inhaler with the same active ingredient (albuterol) and will provide the same quick-acting relief.

Reminder: as of 2014, other excluded rescue inhalers included Maxair Autohaler, Ventolin HFA, and Xopenex HFA. Now, the only suggested alternative is Proair HFA.

The Caremark formulary has the same issue as Express Scripts with the exclusion of Xopenex HFA. As an alternative to the albuterol rescue inhalers, the removal of Xopenex HFA leaves patients who can’t tolerate the side effects without options.

And again, the exclusion of Maxair is nothing to worry about, as it has been discontinued anyway due to its use of CFCs as propellants. You can find more information from the FDA here.

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