If you’ve got health insurance, now’s a good time to be paying attention. Each year, prescription coverage changes, and yours will likely be
changing in 2018.
Express Scripts and Caremark, companies that handle pharmacy benefits for more than 200 million
Americans, are removing more than 80 prescription medications from their formularies at the end of 2017. There is a silver lining for some of you though—almost 20 currently excluded drugs
will be covered in 2018.
Find out below how your coverage may be changing next year.
What are Express Scripts and Caremark?
Express Scripts and Caremark are companies that administer prescription drug benefits for many health insurance companies and Tricare. While you
may have health insurance from Anthem, Aetna or another insurer, your pharmacy benefits are usually handled by these companies or their competitors. They also set the formulary for everyone under
their prescription drug benefit.
What do formulary changes mean for you?
Listed below are brand name drugs for which there may be a less expensive brand or generic alternative available. If your benefits are provided by
Express Scripts or Caremark and you are filling one of these prescriptions, you’ll pay the full cash price at the pharmacy in 2018. (You can see estimated cash prices on GoodRx by clicking on a
pharmacy name after you look up a drug.)
If your coverage is changing, talk to your doctor to see if a covered alternative might work for you. If you can’t switch, you may be able to use
GoodRx or find patient
assistance programs to help cover the cost.
Which drugs are affected?
⇒ Express Scripts: 64 new drugs have been added to the Express Scripts national formulary
The biggest change for many folks will be the exclusion of epinephrine pen Auvi-Qand epinephrine (generic Adrenaclick)—the main competitors
to EpiPen. This isn’t great, but how it affects you will depend on which
version you use, and how much you’re paying now. The Adrenaclick generic has less-expensive cash prices, starting at $110, but EpiPen (and its generic alternative) are still more popular overall.
If you use a long-acting powerful pain medication, you may want to check your coverage—Express Scripts will also be excluding Opana ER and generic oxycodone ER, along
with Lazanda (fentanyl). Abstral and Fentora (also fentanyl pain medications) are already excluded. Your covered options will be mostly generics like hydromorphone ER, morphine sulfate
ER, and fentanyl
To be fair, 46 of 64 newly excluded drugs are simply brand-name drugs that now have a generic alternative—and several of the others are brand-only
drugs with similar generics available in the same class.
⇒ Caremark: 19 new drugs have been added to the Caremark national formulary exclusion list.
Similar to Express Scripts, 5 of these are brands with generic alternatives available, and several others have similar options in the same class.
Diabetes medications appear to have the most new restrictions: injectable Tanzeum, and SGLT2 inhibitors Jardiance, Synjardy, and Synjardy XR will be excluded in
On the other hand, Caremark is adding 19 drugs back to their covered formulary, some as preferred medications and other non-preferred (meaning you
may need a prior authorization or step therapy to get coverage). This is great news, as there are some commonly used medications on this list that don’t have generics or close alternatives. These
include asthma and COPD inhalers Symbicort, Dulera, and Incruse Ellipta; Levitra for erectile dysfunction; and Invokana and Invokamet for diabetes.
2018 Excluded Drugs
You can see all of the excluded medications below. For a full list of excluded drugs and covered alternatives, see the Express Scripts list here and the Caremark list here. If you’re not sure which company provides your pharmacy
benefit, contact your plan administrator.
An important note about Medicare and individual plans:
These changes DO NOT apply to Medicare plans; if your Medicare benefit is managed by Express Scripts, you should check your coverage with your
pharmacist or online through the Medicare.gov
Some individual private insurance plans managed by Express Scripts or Caremark may also have different coverage. This means different drugs may be
covered or excluded on your plan if you have coverage through work, for example. Please get in touch with your insurance provider if you have any questions about your coverage.