Afrezza 2 Tier - 2016 Aetna Pharmacy Drug Guide

[yash]

2016 Aetna Pharmacy Drug Guide
 Two Tier Open Aetna Premier Plan.

See page 22 for afrezza.


fm.formularynavigator.com/MemberPages/pdf/2016AetnaPremierTwoTierOpenFormulary_6908_Full_0.pdf

[EveningOfTheDay]

That's very good news, right? It opens all kind of possibilities for 2016.

[peppy]

Dec 30, 2015 5:56:11 GMT -5 yash said:

2016 Aetna Pharmacy Drug Guide
 Two Tier Open Aetna Premier Plan.

See page 22 for afrezza.


fm.formularynavigator.com/MemberPages/pdf/2016AetnaPremierTwoTierOpenFormulary_6908_Full_0.pdf

2016 Aetna Pharmacy Drug Guide

screencast.com/t/G32Nvt1UH1l

[Deleted]

Dec 30, 2015 5:56:11 GMT -5 yash said:

2016 Aetna Pharmacy Drug Guide
 Two Tier Open Aetna Premier Plan.

See page 22 for afrezza.


fm.formularynavigator.com/MemberPages/pdf/2016AetnaPremierTwoTierOpenFormulary_6908_Full_0.pdf

mnkd.proboards.com/post/54306/thread

While I know little about insurance, it appears to me that in the above linked document, Afrezza is in tier 2 because if you click on the document, it is supposed to be a two-tier formulary. And I also searched the same formulary for 2015. It is the same for 2015 (i.e., Afrezza is already in tier-2 for 2015). And the in both cases, PA is a requirement. So basically no change.



However, I did search the three-tier and four-tier formulary for the AetnaPremier for both 2015 (updated as of August 1, 2015) and 2016 (updated as of December 1, 2015), it does appear that on those plans, while Afrezza is still in tier 3 for 2016, the PA requirement has been removed.



You can google the formulary for yourself.



Assuming that is the case, this is still a huge improvement as I understand the PA requirement has been a huge hurdle for a lot of patients. This is especially the case considering that the Sanofi saving card actually cuts the costs for Afrezza users much further.



I think a tier 3 coverage without PA + Sanofi savings card will be about the same as a tier 2 coverage without PA.



Read more: mnkd.proboards.com/thread/4631/me-afrezza-users-twitter?page=1#ixzz3vo96xcuH

[derek2]

That's a 2-tier formulary. Tier 2 is the lowest tier.

Tier One: You pay the lowest cost for drugs in this level. Your plan may include an additional benefit where some Tier 1 drugs would be provided at an even lower cost to you. These are considered Value Drugs/Tier 1a and include generics and some over-the-counter brand and generic products. These would be available at the lowest cost share indicatedin your plan materials.

Tier Two: You pay a slightly higher cost for drugs in this level.

Still, at least it isn't excluded. The 2-tier plan is more expensive as well.


Even more detail is given in: (page 62)

www.aetnamedicare.com/documents/group/2016/formularies/Aetna_Group_Open1_Enhanced.pdf

Aetna has 2, 3, 4, & 5 tier plans:

2-Tier plan - Afrezza is Tier 2
3-Tier Plan - Afrezza is Tier 3
4-Tier plan - Afrzza is tier 4
3-Tier plus Specialty (4th tier) plan - Afrezza is Tier 3
4-Tier plus Specialty (5th tier) plan - Afrezza is Tier 4

[compound26]

Dec 30, 2015 8:59:46 GMT -5 derek2 said:

That's a 2-tier formulary. Tier 2 is the lowest tier.

Tier One: You pay the lowest cost for drugs in this level. Your plan may include an additional benefit where some Tier 1 drugs would be provided at an even lower cost to you. These are considered Value Drugs/Tier 1a and include generics and some over-the-counter brand and generic products. These would be available at the lowest cost share indicatedin your plan materials.

Tier Two: You pay a slightly higher cost for drugs in this level.

Still, at least it isn't excluded. The 2-tier plan is more expensive as well.

Even more detail is given in: (page 62)

www.aetnamedicare.com/documents/group/2016/formularies/Aetna_Group_Open1_Enhanced.pdf

Aetna has 2, 3, 4, & 5 tier plans:

2-Tier plan - Afrezza is Tier 2
3-Tier Plan - Afrezza is Tier 3
4-Tier plan - Afrzza is tier 4
3-Tier plus Specialty (4th tier) plan - Afrezza is Tier 3
4-Tier plus Specialty (5th tier) plan - Afrezza is Tier 4

It appears the above linked document is only for medicare.  

However, it appears Aetna has many plans.

I am quoting my previous post in another thread below:

I did search the three-tier and four-tier formulary for AetnaPremier for both 2015 (updated as of August 1, 2015) and 2016 (updated as of December 1, 2015), it does appear that on those plans, while Afrezza is still in tier 3 for 2016, the PA requirement has been removed.

Assuming that is the case, this is still a huge improvement as I understand the PA requirement has been a huge hurdle for a lot of patients. This is especially the case considering that the Sanofi saving card actually cuts the costs for Afrezza users much further.

mnkd.proboards.com/post/54306/thread

[derek2]

Dec 30, 2015 9:38:14 GMT -5 compound26 said:

Dec 30, 2015 8:59:46 GMT -5 derek2 said:

That's a 2-tier formulary. Tier 2 is the lowest tier.

Tier One: You pay the lowest cost for drugs in this level. Your plan may include an additional benefit where some Tier 1 drugs would be provided at an even lower cost to you. These are considered Value Drugs/Tier 1a and include generics and some over-the-counter brand and generic products. These would be available at the lowest cost share indicatedin your plan materials.

Tier Two: You pay a slightly higher cost for drugs in this level.

Still, at least it isn't excluded. The 2-tier plan is more expensive as well.

Even more detail is given in: (page 62)

www.aetnamedicare.com/documents/group/2016/formularies/Aetna_Group_Open1_Enhanced.pdf

Aetna has 2, 3, 4, & 5 tier plans:

2-Tier plan - Afrezza is Tier 2
3-Tier Plan - Afrezza is Tier 3
4-Tier plan - Afrzza is tier 4
3-Tier plus Specialty (4th tier) plan - Afrezza is Tier 3
4-Tier plus Specialty (5th tier) plan - Afrezza is Tier 4

It appears the above linked document is only for medicare.  

However, it appears Aetna has many plans.

I am quoting my previous post in another thread below:

I did search the three-tier and four-tier formulary for AetnaPremier for both 2015 (updated as of August 1, 2015) and 2016 (updated as of December 1, 2015), it does appear that on those plans, while Afrezza is still in tier 3 for 2016, the PA requirement has been removed.

Assuming that is the case, this is still a huge improvement as I understand the PA requirement has been a huge hurdle for a lot of patients. This is especially the case considering that the Sanofi saving card actually cuts the costs for Afrezza users much further.

mnkd.proboards.com/post/54306/thread

I agree that removal of PA is positive, as is removal of Step Therapy, which has happened in some plans.

When it comes down to it, brand name drugs priced at a premium will never be Tier 1, which is for the least expensive generics. Tier 2 (of 3 or 4 tiers) is difficult as well, given that it is for generics or preferred brand name drugs. Tier 3 or below is for non-preferred brand name drugs.
See page 9: www.aetnamedicare.com/documents/group/2016/formularies/Aetna_Group_Open1_Enhanced.pdf

What makes a brand name drug "preferred"? According to Express Scripts:

Preferred Brand-Name Drugs

These are drugs for which generic equivalents are not available. They have been in the market for a time and are widely accepted. Express Scripts has arranged a significant discount on these drugs. They cost more than generics, but less than nonpreferred brand-name drugs.




Non-preferred Brand-Name Drugs

These drugs have the highest copayment, and there is a special coinsurance amount of 50 percent for fertility medications. Generally these are higher-cost medications that have recently come on the market. In most cases, an alternative preferred medication is available. If a physician prescribes a brand-name drug when a generic equivalent is available, you must pay the difference in cost in addition to a copayment.

As long as Afrezza costs 2X that of SC insulin, I think Tier 2 will be a tough nut to crack.

[compound26]

Dec 30, 2015 10:21:44 GMT -5 derek2 said:

Dec 30, 2015 9:38:14 GMT -5 compound26 said:

It appears the above linked document is only for medicare.  

However, it appears Aetna has many plans.

I am quoting my previous post in another thread below:

I did search the three-tier and four-tier formulary for AetnaPremier for both 2015 (updated as of August 1, 2015) and 2016 (updated as of December 1, 2015), it does appear that on those plans, while Afrezza is still in tier 3 for 2016, the PA requirement has been removed.

Assuming that is the case, this is still a huge improvement as I understand the PA requirement has been a huge hurdle for a lot of patients. This is especially the case considering that the Sanofi saving card actually cuts the costs for Afrezza users much further.

mnkd.proboards.com/post/54306/thread

I agree that removal of PA is positive, as is removal of Step Therapy, which has happened in some plans.

When it comes down to it, brand name drugs priced at a premium will never be Tier 1, which is for the least expensive generics. Tier 2 (of 3 or 4 tiers) is difficult as well, given that it is for generics or preferred brand name drugs. Tier 3 or below is for non-preferred brand name drugs.
See page 9: www.aetnamedicare.com/documents/group/2016/formularies/Aetna_Group_Open1_Enhanced.pdf

What makes a brand name drug "preferred"? According to Express Scripts:

Preferred Brand-Name Drugs

These are drugs for which generic equivalents are not available. They have been in the market for a time and are widely accepted. Express Scripts has arranged a significant discount on these drugs. They cost more than generics, but less than nonpreferred brand-name drugs.

Non-preferred Brand-Name Drugs

These drugs have the highest copayment, and there is a special coinsurance amount of 50 percent for fertility medications. Generally these are higher-cost medications that have recently come on the market. In most cases, an alternative preferred medication is available. If a physician prescribes a brand-name drug when a generic equivalent is available, you must pay the difference in cost in addition to a copayment.

As long as Afrezza costs 2X that of SC insulin, I think Tier 2 will be a tough nut to crack.

I did a search for 2015 Comprehensive Formulary Aetna Medicare (List of Covered Drugs), see the link below.  And it appears Afrezza was not listed there.

Therefore, it is an improvement in that for at least for certain Aetna medicare plans (not sure whether the formulary I searched covers all medicare plans carried by Aetna), Afrezza was not covered in 2015, but becomes covered in 2016.  

And for the 2016 coverage, the only notation I saw is MO (mail-order).  There is no PA (Prior Authorization) or QL (Quantity Limit) marked with respect to Afrezza.  

dreamboatcruise I recall DBC has been looking for some plan level evidence that Afrezza coverage for 2016 improved vs coverage for 2015. It does appear to me that for certain Aetna plans we just looked at, the coverage is improving (for some plans, PA requirement was removed and for some other plans, Afrezza went from "not covered" to "covered" and without a PA requirement attached).

www.aetnamedicare.com/documents/individual/2015/formularies/15045e-aet-standard-formulary-2gap-2015.pdf