Affordable Care Act
In August, the nation’s two largest pharmacy benefit managers (PBMs)—Express Scripts and the CVS Health — published the list of drugs they’re excluding from their formularies for 2017.
In total, CVS Health will leave 154 prescriptions off of its formularies and Express Scripts will keep 85 drugs off of its formularies next year. Drugs that are not covered will include some treatments for diabetes and hepatitis.
CVS will exclude some drugs that treat cancer as well as some commonly prescribed medications for asthma, including Proventil and Ventolin inhalers. Express Scripts has a policy of not banning drugs for mental health or cancer, but it will stop covering the popular drug, Orencia, which treats people with rheumatoid arthritis.
Others drugs not covered include treatments for the following:
The good news is, these PBMs are still covering “bio-similar” drugs that aim to treat each of the medical problems listed above. In most cases they’re simply not covering the newest or most expensive drug available to treat the problem.
If you’re like most people, you hear the words “pharmacy benefit manager” or PBM and you have no idea what they mean: no, it’s not the guy who manages healthcare benefits for people who work at the pharmacy (good guess, though).
If you get your health insurance from commercial health plan (like Obamacare), an employer-based health plan, Medicare Part D plan, the Federal Employees Health Benefits Program, or a state government employee plan, then a PBM managing your prescription drug benefits.
PBMs get to pick the drugs that go on your formulary, which is the list of drugs that are covered by your health insurance plan. In 2016, PBMs manage pharmacy benefits for 266 million Americans in the U.S.
So, if you think you’re safe from these changes, just be aware that three PBMs cover 78% of the people with prescription drug coverage offered through private insurance – that’s 180 million people.
So, realistically, you’ve got a decent chance of being on one of these plans.
Don’t Despair- First of all, don’t despair. Sometimes PBMs leave expensive drugs off of their formularies in order to pressure drug companies to lower their prices or offer the PBM a better discount. Drug companies know that when their drugs aren’t covered by insurance, people often can’t afford to buy them. Without buyers, the drug company has no sales, and that’s bad for any business. So, just because a drug isn’t covered now, doesn’t mean it can’t make its way back onto formularies in the future.
Shop for health insurance at eHealth.com – In the meantime, if you buy your own health insurance eHealth can help you with our Rx Drug Saver tool, which allows you to type in the names of any prescriptions you take, and it will help you find the “Obamacare” plans (Affordable Care Act plans) that cover your drugs at the lowest available price.
Talk to your doctor about switching medications – Remember the word, “bio-similar.” That’s a fancy way of same a cheaper drug that treats the same illness as your really expensive drug. If your drugs not covered by your health plan, ask your doctor to recommend a bio-similar that is covered.
Don’t take “no coverage” for an answer – Sometimes, a bio-similar just won’t be as good for you as the drug your doctor prescribed. In those instances where your health is at risk, by CVS and Express Scripts have said they’ll work with patients in dire straights to help them pay for needed medications.
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