Post by lakers on Nov 24, 2015 18:08:49 GMT -5
Express Scripts Medicare 2016 Formulary: Afrezza, No PA, ST
ben.omb.delaware.gov/script/documents/medicare/esm-covered-formulary.pdf
pg. 69. Afrezza Tier 3: No PA, ST, QL.
Are there any restrictions on my coverage?
Some covered drugs may have additional requirements or limits on coverage. These requirements and
limits may include:
Prior Authorization: You or your doctor is required to get prior authorization for certain drugs.
This means that you will need to get approval from the plan before you fill your prescriptions. If
you don’t get approval, the drugs may not be covered. These drugs are noted with “PA” next to
them in the formulary.
Some drugs may be covered under Part B or under Part D, depending on your medical condition.
Your doctor will need to get a prior authorization for these drugs as well, so your pharmacy can
process your prescription correctly.
Quantity Limits: For certain drugs, the amount of the drug that will be covered by the plan
is limited. The plan may limit how much of a drug you can get each time you fill your
prescription. For example, if it is normally considered safe to take only one pill per day for
a certain drug, we may limit coverage for your prescription to no more than one pill per day.
These drugs are noted with “QL” next to them in the formulary.
Step Therapy: In some cases, you are required to first try certain drugs to treat your medical
condition before we will cover another drug for that condition. For example, if Drug A and
Drug B both treat your medical condition, we may not cover Drug B unless you try Drug A first.
If Drug A does not work for you, we will then cover Drug B. These drugs are noted with “ST”
next to them in the formulary.
List of abbreviations
LA: Limited Availability. This prescription drug may be available only at certain pharmacies. For
more information, contact Customer Service using the information provided on the front and back
covers of this formulary.
MO: Mail-Order Drug. This prescription drug is available through our home delivery service, as well as
through our retail network pharmacies. Consider using home delivery for your long-term (maintenance)
medications, such as high blood pressure medications. Retail network pharmacies may be more
appropriate for short-term prescriptions, such as antibiotics.
Tier 3:
Non-Preferred
Brand Drugs
This tier includes non-preferred
brand-name drugs as well as
some generic drugs.
Many non-preferred drugs have lower-cost
alternatives in Tiers 1 and 2. Ask your doctor
if switching to a lower-cost generic or preferred
brand-name drug may be right for you.
AFREZZA
INHALATION
CARTRIDGE,
W/INHALATION
DEVICE 4 UNIT, 4
UNIT (30)/ 8 UNIT
(60), 4 UNIT (60)/ 8
UNIT (30)
Drug Tier: 3
Requirements
/Limits: MO
ben.omb.delaware.gov/script/documents/medicare/esm-covered-formulary.pdf
pg. 69. Afrezza Tier 3: No PA, ST, QL.
Are there any restrictions on my coverage?
Some covered drugs may have additional requirements or limits on coverage. These requirements and
limits may include:
Prior Authorization: You or your doctor is required to get prior authorization for certain drugs.
This means that you will need to get approval from the plan before you fill your prescriptions. If
you don’t get approval, the drugs may not be covered. These drugs are noted with “PA” next to
them in the formulary.
Some drugs may be covered under Part B or under Part D, depending on your medical condition.
Your doctor will need to get a prior authorization for these drugs as well, so your pharmacy can
process your prescription correctly.
Quantity Limits: For certain drugs, the amount of the drug that will be covered by the plan
is limited. The plan may limit how much of a drug you can get each time you fill your
prescription. For example, if it is normally considered safe to take only one pill per day for
a certain drug, we may limit coverage for your prescription to no more than one pill per day.
These drugs are noted with “QL” next to them in the formulary.
Step Therapy: In some cases, you are required to first try certain drugs to treat your medical
condition before we will cover another drug for that condition. For example, if Drug A and
Drug B both treat your medical condition, we may not cover Drug B unless you try Drug A first.
If Drug A does not work for you, we will then cover Drug B. These drugs are noted with “ST”
next to them in the formulary.
List of abbreviations
LA: Limited Availability. This prescription drug may be available only at certain pharmacies. For
more information, contact Customer Service using the information provided on the front and back
covers of this formulary.
MO: Mail-Order Drug. This prescription drug is available through our home delivery service, as well as
through our retail network pharmacies. Consider using home delivery for your long-term (maintenance)
medications, such as high blood pressure medications. Retail network pharmacies may be more
appropriate for short-term prescriptions, such as antibiotics.
Tier 3:
Non-Preferred
Brand Drugs
This tier includes non-preferred
brand-name drugs as well as
some generic drugs.
Many non-preferred drugs have lower-cost
alternatives in Tiers 1 and 2. Ask your doctor
if switching to a lower-cost generic or preferred
brand-name drug may be right for you.
AFREZZA
INHALATION
CARTRIDGE,
W/INHALATION
DEVICE 4 UNIT, 4
UNIT (30)/ 8 UNIT
(60), 4 UNIT (60)/ 8
UNIT (30)
Drug Tier: 3
Requirements
/Limits: MO
