That’s because, increasingly, prescription insurers are threatening to kick drugs off their lists of approved medications if the manufacturers won’t give them big discounts.
CVS Caremark and Express Scripts, the biggest prescription insurers, released their 2017 lists of approved drugs this month, and each also has long lists of excluded medications. Some of the drugs newly excluded are prescribed to treat diabetes and hepatitis. The CVS list also excludes some cancer drugs, along with Proventil and Ventolin, commonly prescribed brands of asthma inhalers, while Express Scripts has dropped Orencia, a drug for rheumatoid arthritis.
Such exclusions can take customers by surprise, says Lisa Gill, an editor at Consumer Reports‘ “Best Buy Drugs.”
“We’ve talked to dozens and dozens of people who find themselves at the pharmacy counter, shocked to find out that the drug is no longer covered,” she tells Shots. Patients can appeal the decision in individual cases, but that process can be arduous.
CVS Caremark has been the more aggressive of the two prescription insurers, listing roughly 130 drugs on its “we won’t pay” list. Express Scripts lists 85 and has a policy of not banning cancer drugs or mental health medications.
The threat of kicking drugs off their covered lists — which are known as formularies — is a powerful way to drive discounts, says Adam Fein, CEO of the Drug Channels Institute and author of a blog on prescription drug markets.
“Exclusions are one reason why discounts have been growing,” he tells Shots.
Express Scripts and CVS Caremark only started actively using their lists this way in 2012. Both firms claim they’ve already extracted huge savings for their customers: the health insurance companies and private corporations who hire them to manage their prescription drug plans.
CVS says its formulary management will save its customers $9 billion …