So even though I called Express Scripts a month ago and asked them if my formulary is changing - and they said no - they sent me a letter today saying I can no longer get Novolog or Freestyle Test Strips as of January 1st for my four year old on the Omnipod.
We called Express Scripts today and they said we can not appeal or challenge the formulary decision until January 1st. However, when I called a month ago they said I could appeal right away. The way it was supposed to be appealed was that my doctor had to call into a phone number and discuss the options that we need with a nurse or with a review board.
I know some of you have gone through this already. Has anyone appealed? Can you do it now or have to wait? How was the appeal handled? Has anyone been approved (or denied)? Any other tips / tricks / advice you can offer?
Oh and when we called and asked how they can just make these formulary changes that we need, the rep actually said that Express Scripts owns two thirds of the market and they can do whatever they want. WHA?!?
Your doctor may be able to do a prior authorization to get those approved. I had the same situation. My doctor called my insurance and was approved for a prior authorization for those prescriptions. However, due to the fact they cost more than what oxford covered instead (the humulog and one touch test strips), I decided just to change to save money
I haven’t done an appeal and don’t use express scripts but this is my take on why express scripts did this:
Novonordisk raised the price of novalog because they thought they had enough of the market. Express Scripts figured novalog and a lot of other products were overpriced. The usual way to get consumers to choose lower cost alternatives is to put the expensive drugs/strips on the highest tier and charge a higher copay. Drug companies started giving out copay discount cards to pay the copay for us, defeating the purpose of the tiers. In response, express scripts demanded drug companies including novonordisk lower their prices. Novonordisk and other companies figured express scripts was bluffing and refused. Express scripts then dropped a lot of products including these.
I hope they do offer a solution so people can get the products they really need.
If this affected me, I’d be willing to try humalog but would really insist on the strips because I really think the integrated meter is safer for my 10 year old who doses herself.
Hmm - I use Humalog in my Omnipod but I just called ExpressScripts a week ago and they said it appeared that the Freestyle test strips would be on the formulary as far as they could tell.
We have CVS/Caremark but when I called to refill my daughter's Freestyle test strips a couple of weeks ago, they all of a sudden required pre-authorization when they never had before. Our CDE had to call a certain number and give the authorization explaining that we use Omnipod and must use Freestyle, and they approved it until 2039. Hopefully by then there will be a cure and she won't even need them anymore!
Anyway, I would have your doctor's office call and see if they can get it approved.
Have you tried Levimer? (I think that's the right spelling.) Ask you Doc about it. It is different, but usually is cheaper due to something the maker is doing.
They told me the same thing and then whammo - letter that was three weeks late - and now we can't get them (for now). Keep an eye on them - they are aggressively changing all their formularies IMO.
Thanks for the advice. I would hope there is a process to get what we need since it seems that y'all have done this via a pre-authorization with other companies / situations.
I really want to avoid 1) having to get an authorization for every prescription instead of every drug or 2) having them fill a prescription at full price without insurance because they just do it and then you can't challenge or stop it or send it back because they already sent the medication.
I guess I just need to talk to a supervisor to understand the process better. I've spoken to as many people as I can about this, and haven't found anyone who has appealed formulary decisions with Express Scripts / Medco. Since Omnipod people need the freestyle test strips, I would think that someone had done this by now. We'll continue to post with what I find.
I got the same letter last month . I decided I wouldnt fight the Humalog switch over since its very similar to novalog, but I did talk to the my Human Resource department about the freestyle strips telling them that omnipod has to use freestyle and my daughter was not going to carry around another meter as it could result in her not testing as much as it is too cumbersome and that wasnt safe. So...my human resource department talked to Express scripts and I got grandfathered in.
Jojo - Thanks for this advice! We are going to contact our employer and see if they can do this for us as well.
Yesterday I was told by a supervisor - 1. They don't have an appeals process set up for these specific formulary changes, even though they have one in general. He said this one would be "special appeals process" which scares he half to death, sounds like it will be even harder than normal, 2. Parents / patients will probably have to submit a letter along with a letter from the doctor supporting the claim, 3. that the appeals process will take 3 weeks (just the first round), 4. The appeals process won't be determined, established, or communicated until after January 1st when the changes take effect (and actually need medication, and 5. any changes made will only be good for 6-12 months when we'll have to go through the appeals process again. Holy cow.
I said "What do we do if we need insulin during the appeals process?" and was told "Make sure you have enough to get through this process." ?!? Every 6 months?!?
