Every year, around this time, insurance companies announce the drugs to be removed from their drug formulary lists for the upcoming year. Well, this year’s no different – Express Scripts and Caremark, two of the nation’s largest pharmacy benefit managers (PBMs), which are tied to numerous insurance companies, recently released their lists of drug formulary exclusions.
Insurance drug formulary: what is it?
A drug formulary is a list of medications covered by insurance plans. Generally insurance groups and PBMs update their formularies annually. Since Express Scripts and Caremark are two of the nation’s largest PBMs, they typically get more public interest than smaller PBMs and insurance companies.
How do I know if a drug is covered by my insurance formulary?
Often times you can visit your insurance provider’s website to find the list of drugs covered by your plan. Brand drugs that recently came off patent are generally removed from drug formularies, because a cheaper generic alternative has been made available.
Try Searching the LowestMed Price for your Drug!
Caremark’s new drug formulary approach
In 2017, Caremark will begin taking a new approach to how it chooses which medications will remain on its drug formulary. They are “taking a stand against egregious drug price increases that unnecessarily add costs for clients and their members.”
They will evaluate hyperinflationary drugs to reduce their cost impact. This means, on a quarterly basis, drugs with an egregious cost inflation, that are readily available, clinically appropriate and have more cost effective alternatives, will be evaluated and potentially removed from the drug formulary.
Caremark gives the example of Alcortin, an external gel used to treat skin infections, itching and eczema, which saw a price inflation of 2,856.8 percent in the last three years, as a drug they would evaluate as a hyperinflationary drug.
Caremark will also manage their drug formulary in 2017 by paying more attention to biosimilar drugs. A biosimilar drug is an almost identical copy of the original, but manufactured by a different company. These drugs often cost less than their original brand counterpart.
What if my drug is excluded from the insurance formulary? Now what?
If you find the drug you are prescribed isn’t covered, be sure to shop around for your medication. You can use online price search tools, like LowestMed, to locate pharmacies with the lowest price for your prescription. Unlike your insurance plan, LowestMed does not exclude medications based on a drug formulary list. We provide discounts on all drugs including those on these insurance restricted lists.
These drug formulary exclusions do not apply to Medicare plans. Some plans that are managed by Express Scripts and Caremark may have different inclusions and exclusions on drug formularies. Be sure to check with your insurance provider to make sure your drug is covered.
Caremark formulary exclusions for 2017
All non-Becton Dickinson pen needles and syringes*
Venlafaxine ER Tablets, except 225mg
Express Scripts exclusions for 2017
Abbott (FreeStyle, Precision)
ADV MED TECH (TRUEtest, TRUEtrack)
Bayer (Breeze, Contour)
Doxycycline 40 MG Capsules
Fluorouracil 0.5% Cream
Kineret (Exclude for RA)
Omnis Health (Embrace, Victory)
Simponi 50 MG