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Post by liane on Jul 20, 2017 17:17:42 GMT -5
me, I think you are correct. While a person would have to pay out of pocket for an out-of-network office visit to get a script, the script itself would be covered subject to the patient's formulary.
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Post by sayhey24 on Jul 20, 2017 17:59:22 GMT -5
From the ASM I was under the impression Dachis was going to add "tela" doctors to his service. Prescribing over the internet doesn't seem to be a problem for teladoc www.teladoc.com/prescription-policy/. In fact if CGMs are part of the offering which I suspect they will be One Drop will most likely have some type of 24/7 monitoring. I can sit in my office today and monitor someone across the world in near real time with Dexcom's app.
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Post by dreamboatcruise on Jul 20, 2017 18:41:23 GMT -5
That's very helpful. Do you know if they are, or are planning to do advertising? There is an issue that many insurance plans (most HMOs) don't cover prescriptions if it is a doctor that isn't your assigned PCP or from a authorized referral (or provider network for PPOs). Are you sure about this??? I've been in the employee benefit business for 30 years, sold to some of the largest employers for two large health insurance companies, served on two state health insurance and managed care regulatory bodies, been a CFO for a billion dollars of large group insurance revenues, filed numerous insurance and managed care rates and plans with three different insurance departments, started an HMO, co-founded a managed dental company, worked as a large group employee benefit consultant for an insurance agency and founded a prescription benefit administrator. There are some plans that limit the pharmacies one may use to get a benefit, but I don't think I've ever seen a contract that defines an eligible prescription as having to be written by a participating physician. This would create an administrative nightmare between the plan, its PBM and the pharmacy network. I'm not saying this isn't the case, but I've never seen it. I'd be interested in knowing what plans do this. Are there still staff model HMOs out there (it's been 20 years since I started my HMO), and might they have this limitation? I was administrator for a small company plan and this came up with one employee whose wife needed a VERY expensive drug. The specialist she saw wasn't "in network", so it caused a problem. You may be correct that they don't track that and wouldn't ordinarily catch these things. Since it was 5 digit price per year they checked first to see if it would be covered and told no. They ended up switching doctors. It was small company plan and I know those are not as good as large company plans often. Hopefully your experience is the norm. I just did google search for "will my prescription from out of network doctor be covered" Here is one that appeared. So you can see I'm not making this up. www.quora.com/Can-a-health-insurance-company-refuse-to-pay-for-a-script-written-by-a-doctor-out-of-their-network-in-the-state-of-Virginia-at-leastIn short the question was asked and here is the first bit of the first response, and seems to be from an expert in healthcare... " Dan Munro, Author of Casino Healthcare and Forbes Contributor Answered May 25, 2015 Can they? Absolutely - and it happens frequently.
Out-of-network is dangerous territory when it comes to billable charges - not just for the doctor fees - but also for any prescriptions (or lab tests) written by an out-of-network doctor. "
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Post by me on Jul 21, 2017 9:51:39 GMT -5
Are you sure about this??? I've been in the employee benefit business for 30 years, sold to some of the largest employers for two large health insurance companies, served on two state health insurance and managed care regulatory bodies, been a CFO for a billion dollars of large group insurance revenues, filed numerous insurance and managed care rates and plans with three different insurance departments, started an HMO, co-founded a managed dental company, worked as a large group employee benefit consultant for an insurance agency and founded a prescription benefit administrator. There are some plans that limit the pharmacies one may use to get a benefit, but I don't think I've ever seen a contract that defines an eligible prescription as having to be written by a participating physician. This would create an administrative nightmare between the plan, its PBM and the pharmacy network. I'm not saying this isn't the case, but I've never seen it. I'd be interested in knowing what plans do this. Are there still staff model HMOs out there (it's been 20 years since I started my HMO), and might they have this limitation? I was administrator for a small company plan and this came up with one employee whose wife needed a VERY expensive drug. The specialist she saw wasn't "in network", so it caused a problem. You may be correct that they don't track that and wouldn't ordinarily catch these things. Since it was 5 digit price per year they checked first to see if it would be covered and told no. They ended up switching doctors. It was small company plan and I know those are not as good as large company plans often. Hopefully your experience is the norm. I just did google search for "will my prescription from out of network doctor be covered" Here is one that appeared. So you can see I'm not making this up. www.quora.com/Can-a-health-insurance-company-refuse-to-pay-for-a-script-written-by-a-doctor-out-of-their-network-in-the-state-of-Virginia-at-leastIn short the question was asked and here is the first bit of the first response, and seems to be from an expert in healthcare... " Dan Munro, Author of Casino Healthcare and Forbes Contributor Answered May 25, 2015 Can they? Absolutely - and it happens frequently.
Out-of-network is dangerous territory when it comes to billable charges - not just for the doctor fees - but also for any prescriptions (or lab tests) written by an out-of-network doctor. "The answer from the first respondent (an author) in your link doesn't address the issue directly, but rather describes the creation of a formulary, which has no impact on the question of whether a legal prescription from a non-participating provider can be denied simply because the provider is OON. The second respondent (a licensed insurance agent) in your link, in fact, has the correct answer (which is the point I made above - see bolded). This is the only way a legal prescription written by a non-par provider can be properly denied.
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Post by peppy on Jul 21, 2017 10:40:40 GMT -5
From the ASM I was under the impression Dachis was going to add "tela" doctors to his service. Prescribing over the internet doesn't seem to be a problem for teladoc www.teladoc.com/prescription-policy/. In fact if CGMs are part of the offering which I suspect they will be One Drop will most likely have some type of 24/7 monitoring. I can sit in my office today and monitor someone across the world in near real time with Dexcom's app. In the black box warning; • Before initiating AFREZZA, perform a detailed medical history, physical examination, and spirometry (FEV1) to identify potential lung disease in all patients. (2.5), (5.1)
www.accessdata.fda.gov/drugsatfda_docs/label/2014/022472lbl.pdf
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Post by dreamboatcruise on Jul 21, 2017 12:02:03 GMT -5
meI guess we are not reading it the same. The second answer states that it is dependent on the contract... this is obviously the case. No one disputes that. The problem is how often the exclusion is or isn't in contracts. He doesn't state whether the practice is common or not. However, to me the first author is stating that there are two issues. The question posed was whether the exact same medication covered if prescribed by in network physician would be covered if prescribed by out of network physician. The first part of his answer seems to say that in his experience it happens often. To me raising the second issue of formulary is merely adding on a second issue that patients need to watch out for. I can possibly see the reading you are doing, but to me the logic flow indicates he didn't mean the first clear answer was dependent on the formulary issue. It would also mean he answered a question other than what was asked. Where the differences are between my experience and yours could be interesting but I certainly don't know the answer. Perhaps it has to do with differences in state law, or differences between small company plans, individual plans and large company plans. Perhaps large company plans tend to be better so that they can meet all state laws to give uniform benefits, whereas the other two tend to do the minimum required for a particular state.
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Post by buyitonsale on Jul 21, 2017 16:42:47 GMT -5
Collaboration between MNKD and One Drop will be mutually beneficial. One Drop will gain a complete solution to market their service and achieving even better documented A1C results with Afrezza. They will introduce a durable inhaler device that will become a part of their kit and will provide an Afrezza subscription to patients as a value proposition for a fixed cost. This will provide much needed relief to patients with high deductibles and copays and get insurance approval run around out of the way. For MNKD this will bring the exposure to One Drop's user base and start the ball rolling affect to gain patients as One Drop is a already a successful diabetes service solution. Listen to Jeff Dachis during ASM talk about conceptual collaboration that is coming up (from 18 to 23 minutes in). "Affordable, accessible and clinically effective care" www.youtube.com/watch?v=8us-65oQHwM&feature=youtu.beDDN will not only bring more awareness to Afrezza but will also promote One Drop service as Dash is a user as well.
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Post by agedhippie on Jul 21, 2017 21:19:12 GMT -5
Collaboration between MNKD and One Drop will be mutually beneficial. One Drop will gain a complete solution to market their service and achieving even better documented A1C results with Afrezza. They will introduce a durable inhaler device that will become a part of their kit and will provide an Afrezza subscription to patients as a value proposition for a fixed cost. This will provide much needed relief to patients with high deductibles and copays and get insurance approval run around out of the way. For MNKD this will bring the exposure to One Drop's user base and start the ball rolling affect to gain patients as One Drop is a already a successful diabetes service solution. Listen to Jeff Dachis during ASM talk about conceptual collaboration that is coming up (from 18 to 23 minutes in). "Affordable, accessible and clinically effective care" www.youtube.com/watch?v=8us-65oQHwM&feature=youtu.beDDN will not only bring more awareness to Afrezza but will also promote One Drop service as Dash is a user as well. I think you are missing One Drop's market. If you are on insulin your medical insurance will give you all the strips you need so you no longer need One Drop's delivery service. My bet would be that One Drop's market is mostly Type 2 non-insulin users because they have considerable difficulty getting strips via the insurance route. If Mannkind drop the price to One Drop they have to drop it for everyone. I don't think their cashflow is ready for that.
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