Dropped by Insurance: Will Your Suboxone Be Covered in 2014?

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.

We’re reviewing which prescriptions will no longer be covered and the suggested alternatives to give you a better picture of your options. Caremark has made a change in their coverage of opioid dependence meds that may affect you:

Removed medication: Suboxone film   ||   Suggested Alternatives: buprenorphine/naloxone sublingual tablets

Caremark’s coverage of Suboxone film is being replaced by the sublingual tablet form, which is now only available as generic buprenorphine/naloxone—brand name Suboxone sublinguals have been discontinued.

The Suboxone films and their unit-dose, child-resistant packaging are intended to help limit the accidental pediatric exposure that was an issue with the sublingual tablets. The U.S. Poison Control Centers found out that accidental pediatric exposure with the tablets was 7.8 – 8.5 times greater than with the Suboxone film. Therefore, we may see an increase in the exposure rate of buprenorphine/naloxone tablets in children with parents on Caremark insurance, which is an alarming thought.

Also, the sublingual tablets are not available in the same strengths as the films which may hinder treatment when converting from films to tablets at first. The Suboxone films are available in the following strengths: 2 mg/0.5 mg, 4 mg/1 mg, 8 mg/2 mg, and 12 mg/3 mg. The buprenorphine/naloxone tablets only available in the 2 mg/0.5 mg and 8 mg/2 mg strengths. The 4 mg/1 mg and 12 mg/3 mg film strengths will no longer be an option when switching products.

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.

•  If Caremark handles your coverage, double check the Caremark exclusion list to review the removed medications and alternatives.

•  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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