As you may know from experience, or from one of our previous articles on changes in coverage in 2014 or 2015, it’s typical for prescription benefit managers (PBMs) to exclude medications from their national preferred formularies each year. These may be brands that have generics available, or generally expensive medications where your plan feels a cheaper alternative may work just as well.
It’s less likely that existing drugs will be added back to the preferred formulary (or at least removed from the exclusion list), but that happened this year in several cases for Express Scripts and Caremark—two major PBMs. This could be good news, particularly if you use some popular medications like Advair and Auvi-Q.
There are a few other details to note about these changes—for one thing, just because a medication has been removed from the excluded list, that doesn’t mean that it is now considered a preferred alternative. You may still find that it costs more or falls under a higher tier, even if you do have coverage. Here’s a quick summary of the changes, but you’ll want to contact your plan if you have any questions:
- Advair HFA and Advair Diskus (fluticasone/salmeterol). Removed from the Express Scripts excluded list, and currently an on-formulary option for Caremark plans.
- Rhinocort Aqua (budesonide). Removed from the Express Scripts excluded list, but still excluded on Caremark. Caremark suggested alternatives include prescription Nasonex (mometasone), generic flunisolide, generic fluticasone, and generic triamcinolone sprays.
- Breo Ellipta (fluticasone/vilanterol). Removed from the Caremark excluded list, but still excluded on Express Scripts. Express Scripts suggested alternatives include Dulera and Symbicort.
- Auvi-Q (epinephrine). Removed from the Express Scripts excluded list, and currently an on-formulary option for Caremark plans.
- Avinza (emorphine). Removed from the Express Scripts excluded list, not currently listed as excluded on either formulary.
- Exalgo (hydromorphone ER). Removed from the Express Scripts excluded list, not currently listed as excluded on either formulary.
- Stelara (ustenkinumab). Not only removed from the Express Scripts excluded list, Stelara is now considered a preferred alternative, along with Enbrel and Humira (Cimzia, Simponi, and Xeljanz are still excluded). It is also not currently listed as excluded by Caremark.
High Blood Pressure
- Micardis (telmisartan) and Micardis HCT (telmisartan/hydrochlorothiazide). Removed from the Express Scripts excluded list, and not currently listed as excluded on either formulary.
- Oleptro (trazodone). Removed from the Caremark excluded list, and not currently listed as excluded on either formulary.
What does this mean for you?
When it comes to the conditions these medications can be prescribed to treat, you may have more options this year. Both national formularies still provide a list of covered alternatives as well.
What if your prescription is still 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 another.
- 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 suggested alternatives and they don’t work for you, or if there’s a medical reason why you aren’t able to take the covered medications.
- Finally, get in touch with your doctor and explain that your current prescription will no longer be covered by your insurance in 2015. Show them the list of preferred alternatives. You and your doctor can decide which alternative to try, or how else to move forward with your treatment.
For more information and the full and current 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.