Top

How to Handle CVS Dropping Its Coverage for Viagra

PBMs negotiate discounts and rebates on drugs for insurers.

PBMs negotiate discounts and rebates on drugs for insurers.

CVS Caremark is one of the leading pharmacy benefit managers (PBMs) in the United States.

A pharmacy benefits manager is typically a third party that administers prescription drug programs, though there are PBMs that are parts of large healthcare systems like the Veterans Administration. A PBM is primarily responsible for processing prescription drug claims. They contract with pharmacies, and negotiate discounts and rebates with pharmaceutical companies.

Another task of a PBM is development of a formulary, which is a list of prescription drugs available to people enrolled in insurance that offers drug coverage. Formularies are often “tiered” to provide financial incentives (like lower co-payments) to encourage patients to choose lower-cost drugs.

Formularies can help insurance companies and individuals manage prescription costs better, but some drugs are not included in formularies. With these, patients may have to pay 100% of the cost of the medication, and since drugs not included on formularies are often expensive ones, using a non-formulary drug can be a big expense.

CVS Caremark Formulary Exclusions for 2016

In early August, CVS Caremark released its formulary exclusion list for 2016. The 2016 exclusion list contains 124 products, 31 of which have just been added. So if your insurance uses CVS Caremark as its PBM, and you take one of those 124 products, you’ll be paying more in 2016. Some of the new additions to the 2016 exclusions include some big name drugs, like Abilify, Cymbalta, and the erectile dysfunction (ED) drug Viagra. While it’s possible for excluded drugs to be reinstated on a formulary, it’s not something you can count on, and the details of how a pharmaceutical manufacturer manages to get a drug reinstated are not made public.

Will You Still Be Able to Get Viagra at CVS?

Yes. You’ll still be able to get your prescription for Viagra filled at CVS. But if your insurance uses CVS Caremark as its PBM, you’ll no longer get any price relief on Viagra, so prepare for some degree of sticker shock after January 1 if this is you. A major competitor of Viagra, Cialis, which is made by Eli Lilly & Co., remains on the CVS Caremark formulary for 2016, because the PBM has concluded it is a “cheaper, yet adequate alternative.” So if your insurance uses CVS Caremark as its PBM, starting in 2016, you’ll either need to be prepared to pay more for Viagra, or ask your doctor if you can take Cialis instead.

How CVS Caremark Makes These Determinations

According to CVS Caremark, formularies have two main functions: to provide pharmacy care that’s clinically sound and affordable and to help manage drug spending through appropriate drug therapy choices. Decisions on which drugs are listed in the formulary are made by a committee of clinical pharmacists and physicians who are unaffiliated with CVS Caremark, and CVS emphasizes that the prescribing physician is the ultimate authority on which drug a patient should take.

CVS Caremark says that all decisions are based on “scientific evidence, standards of practice, peer-reviewed medical literature, accepted clinical practice guidelines and other appropriate information.” They also insist the committee doesn’t consider (and indeed has no access to) information on discounts or rebates. The committee reviews the formulary annually, and makes an effort to review drugs in six drug classes for inclusion on an expedited schedule. These drug classes are immunosuppressant drugs, antidepressants, antipsychotics, anticonvulsants, anti-retroviral drugs, and anti-neoplastic drugs.

Can Cialis Always Be Substituted for Viagra?

Cialis and Viagra belong to the same class of drugs: PDE-5 inhibitors. Generally, from a health standpoint, if your doctor says you’re a good candidate to take Viagra, you’re probably a good candidate to take Cialis. For some men, there may be an advantage to taking Cialis – primarily because it has a much longer half-life than Viagra, so the effects last longer. However, each man’s physiology is different, and just because Viagra works well for treating ED doesn’t guarantee that Cialis (or other PDE-5 inhibitors like Levitra) will work equally well. Trial and error is sometimes necessary when trying to determine the best medication for treating ED.

Is Any Other Price Relief on the Horizon?

If you’re in the United States, you’re not going to get much price relief for ED medications until late 2017, when a generic competitor for Viagra is scheduled to be introduced. Teva Pharmaceuticals negotiated a deal with Pfizer (the maker of Viagra) that allows them to introduce their generic before the US patent for Viagra expires in 2020. What Teva had to pay to arrange the deal has not been made public, but the fact that such an agreement was necessary, coupled with the fact that Teva’s drug will be the only generic option in the United States for a while indicates that prices won’t fall precipitously the way they have in Europe, where multiple generics are on the market.

You may find Cialis works for you. It’s still on the CVS Caremark formulary for 2016.

You may find Cialis works for you. It’s still on the CVS Caremark formulary for 2016.

What Should the Committed Viagra User Do?

Men whose insurance uses CVS Caremark as their PBM have several options come January 1. They can pony up the extra money and continue using Viagra as before. They can talk to their doctor about switching to Cialis, since it’s still included in the CVS Caremark formulary. Or they can explore alternative sources for obtaining Viagra. The one thing they should absolutely not do when seeking price relief is search Google for “cheap Viagra” and then order from a questionable website, particularly from a site that says you don’t need a prescription.

Viagra can be bought safely online, as long as you thoroughly vet the source and ensure it’s located in the United States with a street address you can verify on Google Maps. Otherwise, the risk is too high that you’ll end up with a counterfeit product, and if Viagra (real or fake) comes in for you from another country and is snagged by Customs, you could be dealing with legal trouble as well.

Conclusion

Insurance coverage for Viagra and other ED medications is a “nice extra” for many men, since many prescription drug programs don’t cover it at all. But those who are used to getting a discount on Viagra because their insurance uses CVS Caremark as its PBM will face higher costs for Viagra starting in 2016.

eDrugstore.com has worked with US-licensed pharmacists for over 15 years, dispensing genuine Viagra from Pfizer to over half a million customers. We’re committed to competitive prices, the ultimate in convenience, and unbeatable online security and customer service.

Don Amerman has spent more than three decades in the business of writing and editing. During the last 15 years, his focus has been on freelance writing. For almost all of his writing, He has done all of his own research, both online and off, including telephone and face-to-face interviews where possible. Don Amerman on Google+