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Post by stevil on Jan 26, 2023 20:54:33 GMT -5
Already have 1 denial from one Humana MAP, nonformulary.
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Post by nylefty on Jan 26, 2023 21:11:24 GMT -5
If a Medicare patient gets a month's supply of Afrezza for $35 how many dollars does MannKind get?
Would this be a case of losing money on every sale, but writing it off to be able to point to higher script numbers?
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Post by cedafuntennis on Jan 26, 2023 21:51:49 GMT -5
If a Medicare patient gets a month's supply of Afrezza for $35 how many dollars does MannKind get? Would this be a case of losing money on every sale, but writing it off to be able to point to higher script numbers? I doubt it. Medicare would pay the difference to the negotiated price. |
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Post by nylefty on Jan 27, 2023 0:17:03 GMT -5
From the MannKind website.
Emphasis mine.
"Beginning January 2023, Medicare recipients can obtain Afrezza for a copay of no more than $35 a month IF COVERED BY THEIR HEALTH PLAN. There will be no deductible for COVERED insulin products. Coverage WILL REQUIRE AFREZZA APPROVAL WITH A PRIOR AUTHORIZATION OR APPEAL."
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Post by sayhey24 on Jan 27, 2023 7:08:02 GMT -5
Already have 1 denial from one Humana MAP, nonformulary. Did you engage MNKD's help desk after the denial? What did they say? |
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Post by prcgorman2 on Jan 27, 2023 7:20:50 GMT -5
I love this board. Good investigation of important questions and great dialogue. Such a stark contrast to StockTwits and Yahoo! Conversations (which I’ve not checked in years but last I did some idiot was still impersonating my avatar to post FUD). I hope ProBoards and the moderators benefit accordingly.
So since my last post yesterday what I’ve learned from agedhippie, sayhey24, stevil, and our venerable nylefty is that there is no statutory requirement that insurers offering Medicare Part D plans include an inhalable “dosage form” of insulin, and that they are therefore not obligated to cover Afrezza under the $35 monthly co-pay cap.
Now, if the insurer does cover Afrezza, then they have the $35 copay obligation per the IRA. Sadly, this creates a disincentive to cover Afrezza unless Medicare does indeed subsidize the difference between $35 and the discounted retail cost of Afrezza. Anybody have a friend in the insurance business that can find out the answer to that question? I assume the answer is yes, but would like to have it confirmed.
Additionally, stevil confirmed that Humana did decline a Prior Authorization for Afrezza (and I assume specifically declined for a Medicare Part D eligible person with diabetes), so Humana at least in one instance took the easy way out. It makes me wonder if that was a Humana policy or the decision of a Humana representative working the PA request.
Finally, sayhey24 confirmed that at least one or more other insurers who do not have Afrezza listed on their formulary for Medicare Part D coverage nevertheless honored one ore more PA requests, regardless of whether they were obligated. It would be good to know more details on those insurers names, and the particular approvals and get that posted on the Afrezza Facebook community.
Thank you all who contributed to this thread.
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Post by sportsrancho on Jan 27, 2023 8:44:07 GMT -5
I love this board. Good investigation of important questions and great dialogue. Such a stark contrast to StockTwits and Yahoo! Conversations (which I’ve not checked in years but last I did some idiot was still impersonating my avatar to post FUD). I hope ProBoards and the moderators benefit accordingly. So since my last post yesterday what I’ve learned from agedhippie, sayhey24, stevil, and our venerable nylefty is that there is no statutory requirement that insurers offering Medicare Part D plans include an inhalable “dosage form” of insulin, and that they are therefore not obligated to cover Afrezza under the $35 monthly co-pay cap. Now, if the insurer does cover Afrezza, then they have the $35 copay obligation per the IRA. Sadly, this creates a disincentive to cover Afrezza unless Medicare does indeed subsidize the difference between $35 and the discounted retail cost of Afrezza. Anybody have a friend in the insurance business that can find out the answer to that question? I assume the answer is yes, but would like to have it confirmed. Additionally, stevil confirmed that Humana did decline a Prior Authorization for Afrezza (and I assume specifically declined for a Medicare Part D eligible person with diabetes), so Humana at least in one instance took the easy way out. It makes me wonder if that was a Humana policy or the decision of a Humana representative working the PA request. Finally, sayhey24 confirmed that at least one or more other insurers who do not have Afrezza listed on their formulary for Medicare Part D coverage nevertheless honored one ore more PA requests, regardless of whether they were obligated. It would be good to know more details on those insurers names, and the particular approvals and get that posted on the Afrezza Facebook community. Thank you all who contributed to this thread. Thank you for this great summary! And I know how it is to get your picture taken off google and misrepresented on yahoo! Of course, now aged and sayhey are the bad guys on Stocktwits🤣#TheNateCrew #TheyStalkUs Seems getting to the truth is irritating for some people, but I think it’s productive. And we are given the platform here to be able to do it. |
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Post by liane on Jan 27, 2023 9:07:45 GMT -5
Keep in mind, each insurer will have several different plans - each with their own formulary.
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Post by sayhey24 on Jan 27, 2023 9:27:45 GMT -5
I love this board. Good investigation of important questions and great dialogue. Such a stark contrast to StockTwits and Yahoo! Conversations (which I’ve not checked in years but last I did some idiot was still impersonating my avatar to post FUD). I hope ProBoards and the moderators benefit accordingly. So since my last post yesterday what I’ve learned from agedhippie, sayhey24, stevil, and our venerable nylefty is that there is no statutory requirement that insurers offering Medicare Part D plans include an inhalable “dosage form” of insulin, and that they are therefore not obligated to cover Afrezza under the $35 monthly co-pay cap. Now, if the insurer does cover Afrezza, then they have the $35 copay obligation per the IRA. Sadly, this creates a disincentive to cover Afrezza unless Medicare does indeed subsidize the difference between $35 and the discounted retail cost of Afrezza. Anybody have a friend in the insurance business that can find out the answer to that question? I assume the answer is yes, but would like to have it confirmed. Additionally, stevil confirmed that Humana did decline a Prior Authorization for Afrezza (and I assume specifically declined for a Medicare Part D eligible person with diabetes), so Humana at least in one instance took the easy way out. It makes me wonder if that was a Humana policy or the decision of a Humana representative working the PA request. Finally, sayhey24 confirmed that at least one or more other insurers who do not have Afrezza listed on their formulary for Medicare Part D coverage nevertheless honored one ore more PA requests, regardless of whether they were obligated. It would be good to know more details on those insurers names, and the particular approvals and get that posted on the Afrezza Facebook community. Thank you all who contributed to this thread. Thank you for this great summary! And I know how it is to get your picture taken off google and misrepresented on yahoo! Of course, now aged and sayhey are the bad guys on Stocktwits🤣#TheNateCrew #TheyStalkUs Seems getting to the truth is irritating for some people, but I think it’s productive. And we are given the platform here to be able to do it. Pleas thank the Stocktwit people for me for making me the bad guy. I resemble that remark. In going through Facebook it seems Humana is requiring multiple tries and pushes back. There needs to a well defined process the sales reps have outlined for them to work with the doctors to work through Mannkind Cares. They also better be lobbying CMS this year and not drop the ball for 2024. |
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Post by prcgorman2 on Jan 27, 2023 9:34:28 GMT -5
Thank you for this great summary! And I know how it is to get your picture taken off google and misrepresented on yahoo! Of course, now aged and sayhey are the bad guys on Stocktwits🤣#TheNateCrew #TheyStalkUs Seems getting to the truth is irritating for some people, but I think it’s productive. And we are given the platform here to be able to do it. Pleas thank the Stocktwit people for me for making me the bad guy. I resemble that remark. In going through Facebook it seems Humana is requiring multiple tries and pushes back. There needs to a well defined process the sales reps have outlined for them to work with the doctors to work through Mannkind Cares. They also better be lobbying CMS this year and not drop the ball for 2024. And it would be good for MNKD management to engage Humana management to learn the reasons for their reluctance. Is it greed, fear, or ignorance? The first seems least likely (to me) and the last two can be usefully addressed (and with any luck, successfully). |
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Post by stevil on Jan 27, 2023 9:48:05 GMT -5
Already have 1 denial from one Humana MAP, nonformulary. Did you engage MNKD's help desk after the denial? What did they say? Honestly, I don’t even waste time sending stuff to pharmacies. I send all my prescriptions through Afrezza Assist because the initial denial rate is 100%. Every new Rx needs a PA. It’s currently being appealed |
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Post by sayhey24 on Jan 27, 2023 10:09:37 GMT -5
Did you engage MNKD's help desk after the denial? What did they say? Honestly, I don’t even waste time sending stuff to pharmacies. I send all my prescriptions through Afrezza Assist because the initial denial rate is 100%. Every new Rx needs a PA. It’s currently being appealed OK - so its still in process and its working its way through the system. Afrezza Assist is helping which is great news. I think MNKD is going to need to push hard on the 80%+ approval process and get it nailed and maybe get the lawyers involved. Having the right lawyers working the process can sometimes work magic. |
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Post by prcgorman2 on Jan 27, 2023 10:11:06 GMT -5
"Having the right lawyers working the process can sometimes work magic." - sayhey24
AMEN!
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Post by sayhey24 on Jan 27, 2023 10:15:48 GMT -5
"Having the right lawyers working the process can sometimes work magic." - sayhey24 AMEN! Just speaking from experience. The key word is "Right". DC is not unique in this but if they don't have the correct connections they are not getting anywhere. |
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Post by prcgorman2 on Jan 27, 2023 10:22:05 GMT -5
"Having the right lawyers working the process can sometimes work magic." - sayhey24 AMEN! Just speaking from experience. The key word is "Right". DC is not unique in this but if they don't have the correct connections they are not getting anywhere. Exactomundo. Same here. My career has had me engage with numerous IPR, regulatory policy, and lobbyist attorneys (and one NY state legislator). I very much respect what they bring to the table. |
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