Express Scripts…and what to try if your insurance stops covering one of your diabetes supplies

by Leighann on October 29, 2013

Please remember that I never give medical advice. Ask your endocrinologist or pediatrician for advice about your own child. Make your own informed decisions for your own child. We don’t personally use Express Scripts, but many people have mentioned the following predicament to me…

Express Scripts recently announced that it has taken 48 drugs off it’s formulary for 2014. Among them are several very popular diabetes drugs and supplies including:

Test Strips

  • Abbott (Freestyle, Precision)
  • Bayer (Breeze, Contour)
  • Roche (Accu-Chek)

Insulin

  • Apidra
  • Novolog

There are more, but these are probably the most used among people I know. (Here is a PDF of the Express Scripts Exclusions.)

Basically, the company is saying that to avoid paying full price beginning January 1, 2014 for any of the excluded medications, you should have your doctor write a prescription for one of their preferred “covered alternatives.”

Don’t panic.

Okay. Panic a little. But then get busy if you want to try to fix the situation for yourself.

Here are a few things to try. I’m not guaranteeing these actions will see results, but it’s better than sitting there doing nothing and hoping the problem will go away.

1. Switch brands. That was easy.

2. If your insulin pump uses a particular brand of test strip or if a particular insulin has worked well for you, have your endocrinologist write a letter of medical necessity stating why it’s best for you to continue using the same test strips or insulin.

3. Similarly, if one kind of test strips or insulin doesn’t work well for you at all, have your endocrinologist write a letter of medical necessity stating why.

4. Ask for an override.

5. Look on the company websites for patient assistance programs or copay/coupon cards. We use the FreeStyle Promise Program card and save $50 each time we use it.

6. See if there is another way to get prescriptions covered. Do they have a mail order pharmacy? Do they cover a local pharmacy? Can you get any supplies under your durable medical coverage?

7. Write to the pharma companies and tell them that while you love using their product, they need to work with Express Scripts to get back on the covered medications list.

You may be asking why Express Scripts made this decision. There are several reasons (read this Pharmalot interview) but in the grand scheme of things, none of them matter to us when we want to keep using what has been working well in our own diabetes management.

Good luck!

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{ 6 comments… read them below or add one }

1 Wendy October 29, 2013 at 10:40 am

Thanks for the post!

Before Tricare beneficiaries all panic, please note that the exclusions do not impact them – this is for commercial plans only. I just got off the phone with Express Scripts and verified this since we use the Omnipod…

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2 Leighann October 29, 2013 at 4:40 pm

That’s great that you aren’t affected!

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3 Julie October 29, 2013 at 8:40 pm

Thanks for the info
Looks like I better get some contour strips while I can

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4 Kathleen Weaver November 3, 2013 at 9:15 pm

Glad you aren’t affected. Unfortunately not only am I affected BUT I’m allergic to Humalog.

Can’t get an answer from Express Scripts on override.

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5 Sara November 5, 2013 at 12:12 am

According to the link, #5 is actually the reason Express Scripts is doing what they are. Doubling the pain, often those discount cards only work if the prescription is covered at all on your insurance plan. For example, there is a discount card for the iBGStar strips, but I can’t use it because the strips are not listed at all in my coverage.

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6 Nici November 9, 2013 at 11:39 am

I called ExpressScripts yesterday. The agent told me that there is nothing I can do to get Novolog covered. Not under any circumstances. She also confirmed that the only fast-acting insulin they will cover next year is Humalog.

The article you reference says that they only do this with drugs “where clinical outcomes data demonstrates other drugs are equally well suited.” That is not the case with Novolog and Apidra, both of which have a faster uptake and shorter “tail” than Humalog. There are plenty of reports demonstrating this. Also, with Vicotza, there is a fair amount of evidence showing that it is more effective than Byetta.

The sad part is that they will pay more in the long run — due to treatment of increased complications from the post-meal spikes, and hospital stays for the lows on the “tail”. So nobody wins. We have a poorer quality of life and the insurance company pays more anyway. All just to up the ante in a p*ssing contest between big pharma and the insurance companies.

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