Every year, PBMs like Express Script evaluate the clinical value and financial cost of prescription medications and create a list of drugs covered by insurance, known as formularies. For 2019, Express Scripts is set to exclude dozens of drugs from its National Preferred Formulary—the most widely used formulary in the US—with possibly more to come. It’s not all bad news though. Some drugs excluded from the formulary in 2018 will be covered again in 2019.
Here’s how your coverage may change next year.
48 new drugs will not be covered on the Express Scripts National Preferred Formulary beginning January 1, 2019. Of those 48 drugs, about half (22) will be excluded because they are brand-name medications with lower cost generic alternatives.
In 12 separate instances, brand drugs will be excluded because other existing competitors with the same active ingredient cost less. For example, Atripla will be excluded from the 2019 formulary in favor of Symfi and Symfi LO, which is 40% cheaper. Similarly, for the treatment of hepatitis C, Mavyret will not be covered because low-price leader Zepatier—which was excluded from the formulary in 2018—and market leaders Harvoni, Epclusa and Vosevi.
Notably, no products in the irritable bowel syndrome (IBS) or chronic constipation agent class were excluded from Express Scripts’ formulary for 2019. That means Trulance, previously excluded from the formulary in 2018, will be covered again.
New Exclusions for 2019 – Express Scripts National Preferred Formulary
Below is Express Scripts’ new list of excluded drugs as of August 8, 2018. For alternatives to these medications that will be covered, see the exclusion list changes here. If you’re not sure which PBM provides your pharmacy benefits, contact your insurance plan administrator.
Note: Express Scripts states that the list above is not an all-inclusive list of exclusions for their National Preferred Formulary. A full list of excluded products will be available on or before September 5, 2018. Additionally, placement of drugs that treat inflammatory conditions are subject to change.
What do formulary changes mean for you?
The formulary exclusion list above generally includes brand-name drugs for which a less expensive brand or generic alternative is available. If your benefits are managed by Express Scripts and you fill a prescription for any of these drugs, you will likely have to pay the full retail price at the pharmacy. You can find estimated cash prices for each drug on GoodRx.com.
If you notice that coverage for a drug you take will be 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.
An important note about Medicare and private plans:
Some private insurance and Medicare plans managed by Express Scripts may follow a different formulary than the National Preferred Formulary. This means that the list of drugs covered or excluded by those plans may differ from the list above. Please get in touch with your insurance provider if you have any questions about your coverage. If your Medicare benefit is managed by Express Scripts, check your prescription drug coverage with your pharmacist or online through the Medicare.gov portal.
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