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Post by nadathing on Dec 1, 2015 19:45:28 GMT -5
From YMB
"Afrezza*
4 Unit(30) $39.71 90 for up to 30 days (Retail Pharmacy) 4 Unit(60) $75.00 270 for up to 90 days (Mail Service) 8 Unit(60) $58.19 90 for up to 30 days (Retail Pharmacy) 8 Unit(6) $75.00 540 for up to 14 days (Mail order)
I have to believe the 8 unit by mail order is for 90 days and not 14 as stated on the website. Company is self insured. Plan is BCBS New Jersey. Caremark.
*Needs Prior Authorization"
The poster later said he called Caremark and was told that the 12U cartridge is available and that 8U mail order should be 270 for 90 days, copay $75.00
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Post by compound26 on Dec 1, 2015 19:56:45 GMT -5
From YMB "Afrezza* 4 Unit(30) $39.71 90 for up to 30 days (Retail Pharmacy) 4 Unit(60) $75.00 270 for up to 90 days (Mail Service) 8 Unit(60) $58.19 90 for up to 30 days (Retail Pharmacy) 8 Unit(6) $75.00 540 for up to 14 days (Mail order) I have to believe the 8 unit by mail order is for 90 days and not 14 as stated on the website. Company is self insured. Plan is BCBS New Jersey. Caremark. *Needs Prior Authorization" The poster later said he called Caremark and was told that the 12U cartridge is available and that 8U mail order should be 270 for 90 days, copay $75.00 This is consistent with the information shared by Laureen (note that she indicated that she uses 3 boxes each month, so her 90 day supply should be around 9 boxes) regarding Caremark:
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Insurance
Dec 1, 2015 21:08:56 GMT -5
via mobile
Post by mnkdnewbie on Dec 1, 2015 21:08:56 GMT -5
Aetna: 8 unit (60) cart w/dev B (brand) N (non-preferred) at walgreens Your Cost: $100.00 (90 for up to 30 days) annual cost $1,216.67 "Afrezza POW 4 (60) & 8 (30) UNIT Not covered" according to the Aetna "rxtools" 2016 formulary lookup site: Aetna 2016 Prescription Drug Search...none of the other combinations were covered either -- at least for my zip code. That's interesting when I put in my zipcode into your link it also says not covered but it also says medical and pharm plan not available, but when I log into myaetna it tells me the cost for 4 unit and 8 unit.
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Post by dreamboatcruise on Dec 1, 2015 22:22:17 GMT -5
mnkdnewbie... that link is only for Medicare plans. Is that what you have with Aetna?
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Insurance
Dec 1, 2015 22:50:01 GMT -5
via mobile
Post by mnkdnewbie on Dec 1, 2015 22:50:01 GMT -5
mnkdnewbie... that link is only for Medicare plans. Is that what you have with Aetna? O I c, no I have Aetna open access HMO basic
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Post by dreamboatcruise on Dec 1, 2015 22:55:28 GMT -5
mnkdnewbie ... that link is only for Medicare plans. Is that what you have with Aetna? O I c, no I have Aetna open access HMO basic Yep... the link URL even says aetnamedicare.com I think a lot of people here are confused thinking that any given insurance company only has one formulary. They all have many. Often larger companies (Google, GE, etc.) can even tell their insurance companies which drugs they want covered and at what levels. So what applies to one person with a particular insurer may well not apply to someone else... and you're lucky if you can find which formulary you actually belong to, especially if your looking at multiple plans during open enrollment.
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Post by rrtzmd on Dec 2, 2015 9:31:07 GMT -5
O I c, no I have Aetna open access HMO basic Yep... the link URL even says aetnamedicare.com I think a lot of people here are confused thinking that any given insurance company only has one formulary. They all have many. Often larger companies (Google, GE, etc.) can even tell their insurance companies which drugs they want covered and at what levels. So what applies to one person with a particular insurer may well not apply to someone else... and you're lucky if you can find which formulary you actually belong to, especially if your looking at multiple plans during open enrollment. "They all have many," is an understatement. Looking further on Aetna's website, I found more than I bargained for. Here are a couple: Three Tier Open Aetna Premier PlanFive Tier Open Aetna Value Plus PlanThey show it as tier 3 and requiring prior approval and step therapy. Then there's the "premier plus plan": premier plus planIt just shows it as being tier 3.
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Post by suebeeee1 on Dec 3, 2015 17:03:08 GMT -5
I have United Healthcare and the cost of Afrezza, currently not covered under my plan is $331.96 for a 30-day supply and $905.42 for a 90-day supply. This is all out of pocket. I don't know where you are, but we live in Virginia, and have been assured that all United Health Care plans will be covering it on their Tier 3 as of January 1 (in Writing!!!)
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Post by wiscdh on Dec 3, 2015 17:11:35 GMT -5
I live in Wisconsin.
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Post by compound26 on Dec 3, 2015 17:39:42 GMT -5
Can you then switch insurance to get a better coverage for 2016? Or is that not a practical option for you? And how many boxes you are using in one month and 90 days? lookup.decisionresourcesgroup.com/And if you are able to switch insurance, go ahead switch and then write a letter to UHC informing them that you have to switch insurance because they do not cover Afrezza. With enough people switching, the insurance companies will have to wake up and beef up their coverage for Afrezza.
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Post by matt on Dec 4, 2015 15:41:57 GMT -5
Remember that virtually all the big insurance companies are both true insurance companies, where they take the financial risk, and third-party administrators of plans for which they bear little to no financial risk. Most large companies are self-insured but delegate administration of the paperwork to a third-party administrator (TPA).
If a self-insured plan directs the TPA that they want Afrezza covered, it will be. The TPA doesn't really care because the final cost will ultimately be billed 100% to the company. My daughter works in a specialized company that does nothing but arrange preapprovals for very expensive medications (the kind that run more than $5,000 a pop) and the preapproval is often turned down the first time. If a plan is self-insured, the patient can often go to human resources at their company and get the drug covered. Insulin is a different animal, but some companies with great benefit plans may be happy to cover it, but they specifically have to be asked to do so. The self-insured companies start with a recommended formulary from the TPA and tweak it from there; developing formularies and health plans is not what most companies do which is why they have the TPA to begin with. As a friend of mine used to say "You have a no, but if you ask you might get a yes".
When the insurers themselves are financially at risk, like most Obamacare marketplace plans, Afrezza will be a hard sell absent a change in label copy, and Sanofi is years away from having the studies they need to support a label change. The fact is that while Afrezza may lower healthcare costs long-term, the average insured changes their carrier within three years so the long-term savings will accrue to a DIFFERENT insurance company. All the insurers know this so any drug that does not deliver a net savings within 36 months is not getting covered if there are cheaper alternatives available. Those are the hard facts of life in the insurance world, and the situation is not likely to change anytime soon.
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Post by vestful on Dec 5, 2015 11:36:00 GMT -5
Remember that virtually all the big insurance companies are both true insurance companies, where they take the financial risk, and third-party administrators of plans for which they bear little to no financial risk. Most large companies are self-insured but delegate administration of the paperwork to a third-party administrator (TPA).
If a self-insured plan directs the TPA that they want Afrezza covered, it will be. The TPA doesn't really care because the final cost will ultimately be billed 100% to the company. My daughter works in a specialized company that does nothing but arrange preapprovals for very expensive medications (the kind that run more than $5,000 a pop) and the preapproval is often turned down the first time. If a plan is self-insured, the patient can often go to human resources at their company and get the drug covered. Insulin is a different animal, but some companies with great benefit plans may be happy to cover it, but they specifically have to be asked to do so. The self-insured companies start with a recommended formulary from the TPA and tweak it from there; developing formularies and health plans is not what most companies do which is why they have the TPA to begin with. As a friend of mine used to say "You have a no, but if you ask you might get a yes".
When the insurers themselves are financially at risk, like most Obamacare marketplace plans, Afrezza will be a hard sell absent a change in label copy, and Sanofi is years away from having the studies they need to support a label change. The fact is that while Afrezza may lower healthcare costs long-term, the average insured changes their carrier within three years so the long-term savings will accrue to a DIFFERENT insurance company. All the insurers know this so any drug that does not deliver a net savings within 36 months is not getting covered if there are cheaper alternatives available. Those are the hard facts of life in the insurance world, and the situation is not likely to change anytime soon. Matt - Please keep posting as you sound more knowledgeable than most regarding insurance.
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Post by dreamboatcruise on Dec 5, 2015 14:36:20 GMT -5
Remember that virtually all the big insurance companies are both true insurance companies, where they take the financial risk, and third-party administrators of plans for which they bear little to no financial risk. Most large companies are self-insured but delegate administration of the paperwork to a third-party administrator (TPA).
If a self-insured plan directs the TPA that they want Afrezza covered, it will be. The TPA doesn't really care because the final cost will ultimately be billed 100% to the company. My daughter works in a specialized company that does nothing but arrange preapprovals for very expensive medications (the kind that run more than $5,000 a pop) and the preapproval is often turned down the first time. If a plan is self-insured, the patient can often go to human resources at their company and get the drug covered. Insulin is a different animal, but some companies with great benefit plans may be happy to cover it, but they specifically have to be asked to do so. The self-insured companies start with a recommended formulary from the TPA and tweak it from there; developing formularies and health plans is not what most companies do which is why they have the TPA to begin with. As a friend of mine used to say "You have a no, but if you ask you might get a yes".
When the insurers themselves are financially at risk, like most Obamacare marketplace plans, Afrezza will be a hard sell absent a change in label copy, and Sanofi is years away from having the studies they need to support a label change. The fact is that while Afrezza may lower healthcare costs long-term, the average insured changes their carrier within three years so the long-term savings will accrue to a DIFFERENT insurance company. All the insurers know this so any drug that does not deliver a net savings within 36 months is not getting covered if there are cheaper alternatives available. Those are the hard facts of life in the insurance world, and the situation is not likely to change anytime soon. I knew many large companies could tailor their drug plans. I didn't realize that was mostly tied to being self insured, but that would certainly make sense. I've often expressed the same sentiment regarding a lack of long term incentive for preventing complications. I've spoken with a friend associated with a big health organization known for "evidence based" medicine and he admits that there still is a tendency to favor short term evidence over the long term kind. It seems like there are two possibilities that might significantly change the landscape... 1) diabetes organizations such as ADA change guidelines to lower target A1c levels or 2) SNY makes the case for financial benefit of less hypos (a near term savings). The later would be a pure dollars and cents argument, and it might require a price reduction from where we are now.
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