Medicare Part D Coverage for Afrezza

[prcgorman2]

I copied the below from the ABC “Afrezza wins” thread because I think the topic deserves it’s own thread and this was a good bit of due diligence by SR71 (followed by an informative response from Sayhey but I couldn’t select and copy 2 posts at the same time).

sr71 Avatar
Nov 17, 2022 19:01:48 GMT -6 sr71 said:
sayhey24 Avatar
Nov 17, 2022 14:57:27 GMT -6 sayhey24 said:
OK mystery solved. What Mike said was a little misleading. It sounded like it "should" be covered but it seems it is covered and there are so many plans its hard to figure out one which does not cover it but I would say they all have they cover it as "Inhaled Insulin".

I went to medicare.gov and did a search for my zip code for afrezza and got a zillion plans covering afrezza. For 2022 the cost through Aetna would be about $30k for the year. For 2023 I got this notice

Important! Starting January 1, 2023, the cost of a one-month supply of each Part D-covered insulin will be capped at $35. If you get a 60- or 90-day supply of insulin, your costs can’t be more than $35 for each month’s supply of each covered insulin.

This new $35 cap may not be reflected when you compare 2023 plans. You should talk to someone for help comparing plans.

Who gets the credit for this? Mike? Kevin Sayer? someone else? It looks like a big win.
sayhey -

I used the search on medicare.gov you suggested, but ALL the Part D plans for my zip code listed Afrezza 8 unit cartridges (90 count) as costing over $1,000 per month.

But I noticed a Medicare Chat feature, so I tried it out hoping to get a definitive answer for if Afrezza is included for the $35 copay. Here's the Chat transcript:

------------------- Medicare.gov Live Chat Transcript ---------------------
Live chat Date:11/17/2022
Start Time:2:25:53 pm
End Time:2:33:01 pm
-----------------------------------------------------------------------------

[2:25:53 pm]: Thank you for contacting Medicare.gov Live Chat.
[2:25:56 pm]: James I'm using the Part D Plan Comparator tool to find coverage for the insulin drug Afrezza 90 8 unit cartridges, and at the top of the screen it says that it is covered with a 35 Dollar copay per month. But when I enter any 5 of the pharmacies, ALL Part D plans come up with an annual cost of Afrezza in excess of 12,000 Dollars. How do I get the 35 Dollar copay only price?
[2:25:58 pm]: Please wait while you are connected to an agent.
[2:26:05 pm]: You are now connected with Medicare.gov Live Chat.

Thank you for contacting Medicare.gov Live Chat. My name is Jessica. For privacy purposes, please do not disclose any personal information such as your Social Security Number, Medicare ID, or any other sensitive medical or personal information.
[2:26:25 pm]: James OK.
[2:27:05 pm]: Jessica I'll be happy to assist you.

[2:27:14 pm]: Jessica Please allow a few moments while I review your questions.

[2:28:31 pm]: Jessica The Inflation Reduction Act sets a maximum copayment of $35 for a month’s supply of insulin covered by a plan. You won’t have to pay a deductible, if your plan has one, for your covered insulin.
[2:28:40 pm]: Jessica Because this act was passed close to the start of Medicare’s open enrollment period, the plans didn't have a chance to submit updated prices for insulin drugs that appear in the Medicare Plan Finder.
[2:28:56 pm]: Jessica If you join a stand-alone prescription drug plan or Medicare Advantage plan with drug coverage, you will pay up to $35 a month for insulin covered by the plan during all phases of coverage.
[2:30:47 pm]: James Can you confirm if Afrezza is in fact an insulin that is covered and subject to only the 35 Dollars per month copay for 2023?
[2:31:53 pm]: Jessica You would need to call the plan, the information we have been provided is all insulin qualifies.
[2:32:44 pm]: James Thank you very much for your response.


Not sure that is a definitive answer, though, so I also called my Part D provider (Aetna), who stated that Afrezza is not on their formulary for 2023, is not covered, and therefore is not subject to the $35 monthly copay amount.

If Mike Castagna is serious about Afrezza being covered by any Part D providers for 2023, he should issue a press release listing the Medicare Part D plans that are actually offering this coverage for Afrezza.

This issue is pivotal for Mannkind since the Afrezza price barrier could be coming down.

And imagine what VDEX could/would be able to do to help many, many more people effectively gain control their diabetes!

[peppy]

"Not sure that is a definitive answer, though, so I also called my Part D provider (Aetna), who stated that Afrezza is not on their formulary for 2023, is not covered, and therefore is not subject to the $35 monthly copay amount."

"Important! Starting January 1, 2023, the cost of a one-month supply of each Part D-covered insulin will be capped at $35. If you get a 60- or 90-day supply of insulin, your costs can’t be more than $35 for each month’s supply of each covered insulin."

Catch 99.

[nylefty]

In other words, Medicare insurance plans are free to cover or not cover Afrezza, but if they do so they can only charge $35 a month for it. I hope most of them will do that, but I'm afraid most will join Aetna in saying No Thanks. 

[agedhippie]

Aetna seems to have done a deal with Novo Nordisk since their formulary only lists Novo insulins with the exception of the U-500 insulin which I think only Lilly makes.

[peppy]

Nov 18, 2022 9:29:29 GMT -5 agedhippie said:

Aetna seems to have done a deal with Novo Nordisk since their formulary only lists Novo insulins with the exception of the U-500 insulin which I think only Lilly makes.

that must be the ticket..... rebates and all. catch 1

[sayhey24]

Nov 18, 2022 0:51:58 GMT -5 nylefty said:

In other words, Medicare insurance plans are free to cover or not cover Afrezza, but if they do so they can only charge $35 a month for it. I hope most of them will do that, but I'm afraid most will join Aetna in saying No Thanks. 

After doing some research on this my understanding (which may not be 100% correct but I think it is)  EVERY Plan D plan has to cover at least one form of every insulin type.  "Inhaled" is an insulin form and types are rapid acting, etc.  Since the only available "inhaled" insulin is afrezza, they all by law have to cover it.

In other words every plan has to cover at least one form of afrezza.  They don't have to include all cartridge sizes but they have to include at least one.  Most seem to cover various box types 4, 8. 4+8, titration, and 12.

For Aetna in my zip code I can sign up for the below.  Peppy if you have Aetna it should include it. PM me your zip and I will look. I would like to see if I fully understand how this works now.  Understanding Medicare can be overwhelming.  It took me several months to understand the various plans.

In my zip it definitely includes afrezza and will get covered at $35 starting 1/1/2023.  For the below I selected the 4u box.

SilverScript SmartSaver (PDP)

Aetna Medicare | Plan ID: S5601-181-0

Star rating:

3.5 stars

MONTHLY PREMIUM

$5.20

Includes: Only drug coverage



YEARLY DRUG & PREMIUM COST

$6,188.76

Retail pharmacy: Estimated total drug + premium cost



$6,188.72

Mail-order pharmacy: Estimated total drug + premium cost

[prcgorman2]

Nov 18, 2022 0:51:58 GMT -5 nylefty said:

In other words, Medicare insurance plans are free to cover or not cover Afrezza, but if they do so they can only charge $35 a month for it. I hope most of them will do that, but I'm afraid most will join Aetna in saying No Thanks. 

Based on sayhey's logic, ever insurer who offers insulin coverage must cover for every type of insulin including inhalable.  There is only 1.  Now, holding the insurance providers' feet to the fire to ensure that happens might be interesting, but the logic seems inescapable.

[sayhey24]

Nov 18, 2022 9:29:29 GMT -5 agedhippie said:

Aetna seems to have done a deal with Novo Nordisk since their formulary only lists Novo insulins with the exception of the U-500 insulin which I think only Lilly makes.

OK - but Novo Nordisk does not have an inhaled insulin.  Each part D plan by law has to include one form of each; pen, vial and inhaled for each insulin type - rapid acting, intermediate, etc

Lilly is no longer making Exubera.  If they were then Exubera would be competing with afrezza for inclusion as long as they are both in the rapid insulin type.

[sayhey24]

Nov 18, 2022 10:40:28 GMT -5 prcgorman2 said:

Nov 18, 2022 0:51:58 GMT -5 nylefty said:

In other words, Medicare insurance plans are free to cover or not cover Afrezza, but if they do so they can only charge $35 a month for it. I hope most of them will do that, but I'm afraid most will join Aetna in saying No Thanks. 

Based on sayhey's logic, ever insurer who offers insulin coverage must cover for every type of insulin including inhalable.  There is only 1.  Now, holding the insurance providers' feet to the fire to ensure that happens might be interesting, but the logic seems inescapable.

I sure hope I am right but it seems like the Inflation Reduction Act did for afrezza what no study or trial could.

Its the law.  If your Plan D is not listing afrezza by law it has to and all you need to do is contact you congressman.

Here is a good article which was updated in September

www.ncoa.org/article/diabetes-and-insulin-a-guide-to-paying-with-medicare

[sayhey24]

As a recap this is what Mike said on the 3Q2023 call

"In 2023, we fully expect that Afrezza will be covered in Medicare at $35 under the Inflation Protection Act bill that was passed. That changes the game as one of the major objectives for Afrezza's around access, and we really want to continue to see that patients can only have to pay $35 for Afrezza"

Aside from it being the "Inflation Reduction Act" Mike is 100% correct and coverage starts 1/1/2023.

DXCM and Abbott now have a big reason to want to sell afrezza and get the doctors off the oral agents in the T2 market . Any patient using afrezza would also qualify for a free CGM.

[cretin11]

Words not often heard: Thank you Congress!

[peppy]

Nov 18, 2022 10:55:58 GMT -5 sayhey24 said:

As a recap this is what Mike said on the 3Q2023 call

"In 2023, we fully expect that Afrezza will be covered in Medicare at $35 under the Inflation Protection Act bill that was passed. That changes the game as one of the major objectives for Afrezza's around access, and we really want to continue to see that patients can only have to pay $35 for Afrezza"

Aside from it being the "Inflation Reduction Act" Mike is 100% correct and coverage starts 1/1/2023.

DXCM and Abbott now have a big reason to want to sell afrezza and get the doctors off the oral agents in the T2 market . Any patient using afrezza would also qualify for a free CGM.

Sayhey, I think we need something that lists the insulin types medicare covers. 
Is there any document you can come up with that says medicare covers inhalable insulin?

I read, Pens and pumps.

www.medicare.gov/coverage/insulin

Part D covers these:

Injectable insulin that isn’t used with a traditional insulin pump
Insulin used with a disposable insulin pump
Certain medical supplies used to inject insulin, like syringes, gauze, and alcohol swabs
If you use an external insulin pump that isn’t disposable, Part B may cover insulin used with the pump and cover the pump itself as durable medical equipment (DME). If you live in certain areas of the country, you may have to use specific insulin pump suppliers for Medicare to pay for a durable insulin pump.

[peppy]

Nov 18, 2022 10:55:58 GMT -5 sayhey24 said:

As a recap this is what Mike said on the 3Q2023 call

"In 2023, we fully expect that Afrezza will be covered in Medicare at $35 under the Inflation Protection Act bill that was passed. That changes the game as one of the major objectives for Afrezza's around access, and we really want to continue to see that patients can only have to pay $35 for Afrezza"

Aside from it being the "Inflation Reduction Act" Mike is 100% correct and coverage starts 1/1/2023.

DXCM and Abbott now have a big reason to want to sell afrezza and get the doctors off the oral agents in the T2 market . Any patient using afrezza would also qualify for a free CGM.

sayhey messaged me, saying he found afrezza on my silver script formulary and I can pick it up at Sam's Club or Walmart for 35 bucks.  (probably on the first of the year?)

wow, 

The more MNKD makes of Afrezza the cheaper the cost to a point.

[sayhey24]

Peppy - here is a good overview
boomerbenefits.com/whats-going-on-with-medicare-and-insulin-coverage/#:~:text=When%20it%20comes%20to%20injectable

This was written in 2020 before the Inflation Reduction Act

"Insurers aren’t required to include every type of insulin in their Senior Savings Model plan formularies; they could choose to cover an insulin pen from one manufacturer but not from another. However, they must cover at least one pen-dosage form and one vial-dosage form for each type of insulin (short-acting, intermediate-acting, long-acting, and rapid-acting) in their formulary"

[peppy]

Does Medicare cover insulin?
There is no coverage for insulin under Original Medicare (Part A and Part B) in most cases. There’s an exception for individuals who use an insulin pump, however.

If your doctor prescribes an external insulin pump, it may be covered under Part B’s durable medical equipment benefit. If Medicare approves your insulin pump, it also pays for the insulin used with the pump. You pay 20% of the allowable charges after meeting your Part B deductible. When it comes to injectable and inhaled insulin, there’s generally no coverage under Part A and Part B.

However, Medicare Part D prescription drug plans are required to cover injectable and inhaled insulin. The new Medicare savings program is designed to work with Part D plans and changes how plan sponsors and drug manufacturers pay insulin costs for Medicare beneficiaries. Instead of tiered copayments and percentage-based coinsurance, the new savings model caps out-of-pocket insulin costs at just $35 per prescription.

========================================================================================================

There it s.

boomerbenefits.com/whats-going-on-with-medicare-and-insulin-coverage/#:~:text=When%20it%20comes%20to%20injectable

Thank you sayhey, they have to.
Now we need to get the word out.

Facebook Afrezza group talking about this?

alethea.   give it a go?