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Express Scripts to only cover Humalog and One Touch strips

Discussion in 'Insurance Issues' started by lilituc, Oct 28, 2013.

  1. lilituc

    lilituc Approved members

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    Sorry if this was posted before; I didn't find it when I searched. Those of us with Express Scripts as our pbm are getting letters informing us that Express Scripts is excluding Novolog, Apidra, and many test strips from their formulary as of January 1st. Meaning that they will not be covered by Express Scripts.

    Here is an interview with the CMO, explaining some background on why they decided to do this: http://www.pharmalive.com/why-express-scripts-tossed-48-drugs-off-its-formulary-miller-explains There is a link to the full list of exclusions in the article.

    Does anyone know if we have any options here?
     
  2. Mom2Av

    Mom2Av Approved members

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    I'm being told I can appeal to my insurance company, but I doubt that is going very far. I would love to think an email campaign would work to get them to keep Novolog, but I bet it all boils down to the drug company that gave them the most Money!:mad:
     
  3. swellman

    swellman Approved members

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    Is it the pharmacy or the insurance provider who determines the formulary? I thought it was the insurance plan.

    EDIT: Woops ... nevermind. Wow.
     
  4. BrendaK

    BrendaK Neonatal Diabetes Registry

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    I'm guessing that we are some of the 2% of customers that are affected. Yikes. Will be waiting for our letter and talking to our endo. Haven't used Humalog since Carson started pumping 8.5 years ago. Thanks for the link.
     
  5. swellman

    swellman Approved members

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    Can't you get it from somewhere else or do you have to go through Express Scripts. It seems to me that they can't dictate you medication ... stop carrying it, yes, but they can't prevent you from filling the Rx elsewhere can they?

    I guess I'm getting confused by a mail order pharmacy and insurance.
     
  6. KatieSue

    KatieSue Approved members

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    We don't have Express Scripts but our insurance deems that any prescription refilled more than twice MUST be via mail order. So in our case the insurance company is deeming we must use a specific mail order company for recurring prescriptions. The insurance doesn't say it's not covering novalog for instance but it makes you use a specific mail order company that may say they're not carrying it. Clear as mud right?
     
  7. swellman

    swellman Approved members

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    That doesn't seem legal. I would wager it's relatively easy to get a waiver.
     
  8. KatieSue

    KatieSue Approved members

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    It may be easy to work around we've never needed to try. We do pay a ton more for her strips because they're not the "preferred brand". But they're not out an out not covered at all just cost us more.
     
  9. swellman

    swellman Approved members

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    Yea, when we switched insurance last year we switched meters even though we have PDM that uses Freestyle to Verio IQ. That switch saved us $600 because the copay for the Verio is $10 for 3 months.
     
  10. Jordansmom

    Jordansmom Approved members

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    Most of us with Express Scripts have our Rx coverage part of our medical insurance separated out and managed by Express Scripts. For instance, we have BCBS medical. Medical claims show up on the BCBS system. You call BCBS if you have a medical claim problem. But Rx claims go through Express Scripts and only show up in the Express Scripts system. They manage prescriptions that are run through local pharmacies as well. So they do dictate to us that we can only fill name brand medications twice before we are forced to use their mail order system. And they do dictate what meds are covered.

    I'm doubtful it will be easy to get a waiver in this case since they are not covering these medications at all. I doubt they will stock them. It's different than just getting an exception for non preferred medications or strips.

    Apparently Express Scripts is fighting with these pharma companies over co-pay savings cards. They tried in various ways to eliminate them. When they failed, they excluded expensive meds that have co-pay savings from their policies. Then they claimed it was because these meds don't have any clinical benefit over cheaper drugs they do cover.

    http://www.forbes.com/sites/edsilverman/2013/10/21/bye-bye-co-pay-cards-why-express-scripts-is-excluding-dozens-of-drugs/
     
  11. swellman

    swellman Approved members

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    I see, when we had Medco-> Express Scripts it was different for us as they were just a mail order pharmacy. They were cheaper and had limitation on what you could purchase locally but if they didn't carry something we could have gone to CVS. That stinks.
     
  12. Megnyc

    Megnyc Approved members

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    For me express scripts is my insurance and my pharmacy.

    I can get free prescription coverage through work and only get stuff through express scripts after 2 retail fills or pay a negligible amount ($30 a month I think) and be allowed to use a retail pharmacy whenever I want (that's what I do). I get dexcom sensors through a retail pharmacy because express scripts is incompetent and kept sending me transmitters instead of sensors. I also get insulin through retail because they insist on mailing it in an unpadded plastic envelope and it comes all squashed and banged up and that worries my parents.

    I already switched to onetouch verio strips because they work fine and I don't feel like dealing with a retail pharmacy every month for strips. But I don't want to switch from apidra. I'm trying to figure out if I can still get apidra from a local pharmacy if they are going to be then billing express scripts for it. Maybe someone here knows?
     
  13. lilituc

    lilituc Approved members

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    If Express Scripts is your pharmacy benefits manager, they won't pay for it after January 1st. You can of course fill your prescription at any pharmacy if you pay the entire cost yourself. Does that answer your question?
     
  14. lilituc

    lilituc Approved members

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    Sorry for the confusion! I didn't even realize Express Scripts had a pharmacy. Yes, in this case, it means when Express Scripts is your pbm through your insurance company they will no longer cover the drugs on that list at all...at any pharmacy.

    I don't know about where you live, but my pharmacy charges about $155 for a vial of Novolog.
     
  15. danismom79

    danismom79 Approved members

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    It's a little confusing for me, too, but I guess some people have their prescriptions managed solely by Express Scripts. I have to use them for mail orders, but if I fill a script at Walgreens, they have no say and no record of it.
     
  16. mamattorney

    mamattorney Approved members

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    This just seems like a case of a business practicing medicine and I don't like it. I feel bad for anyone that this personally affects.

    My husband's former cardiologist retired because of things like this. He said he was tired of the insurance companies treating each of his patients the exact same way. Some patients need more aggressive testing/treatment due to family history or other reasons, but the insurance companies liked everyone to march down the same straight line. He felt like his hands were tied and it really weighed on his conscience.
     
  17. kathweaver

    kathweaver New Member

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    Allergic to Humalog

    I'm horribly upset as I am allergic to Humalog and all of Lily's products and Express Scripts currently doesn't no how they are going to handle that.
     
  18. kathweaver

    kathweaver New Member

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    Allergic to Humalog

    I'm allergic to Humalog and am on Express Scripts.

    I've been trying to get an answer from Express Scripts on what they are going to do about that but they don't have an answer yet, the one person I've talked to is hoping they have override.
     

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