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Post by sellhighdrinklow on Feb 21, 2018 14:15:14 GMT -5
btw, fwiw, Express Scripts does not work with Blue Shield of California.
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Post by agedhippie on Feb 21, 2018 15:41:00 GMT -5
Amazon cover all insulin, including Afrezza, at the same tier and without prior authorization. That's interesting because their plan is administered by Express Scripts so they obviously are not using Express Scripts formulary which makes it a good example of a company directing it's PBM not to take the cheapest path. Amazon may well be self insured, and the PBM is thus merely acting as a plan administrator. Especially in that situation, the PBM will pretty much put whatever drugs the company wants on the formulary. Doesn't surprise me that Amazon has top notch coverage. At their headquarters don't they provide unlimited custom made gourmet donuts delivered right to your desk... along with the insulin. I am 100% certain Amazon must self-insure, at their scale nothing else makes sense, so I expect the PBM to just administer what they are told to. Maybe the donuts depend on if there is a local Whole Foods nearby The insulin would be a necessity (visions of half the staff in a diabetic coma from all the donuts). Actually Amazon is amazingly tightfisted with benefits - for those you need Facebook or Google.
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Post by matt on Feb 22, 2018 10:24:07 GMT -5
Amazon may well be self insured, and the PBM is thus merely acting as a plan administrator. Especially in that situation, the PBM will pretty much put whatever drugs the company wants on the formulary. Indeed, most employers of a certain size are self-insured and whether you are talking about the managed care company that processes claims or a PBM, the employer ultimately calls the shots on what is and is not covered. In those cases, the managed care company and PBM are used as a TPA (third-party administrator) on a fee-for-service basis with the TPA paid a fixed fee for each claim or script processed. This makes sense for the employer because the TPA has the necessary systems and infrastructure to process claims much more efficiently than if the employer tried to do it themselves. This is a very important distinction that many people misunderstand. A large employer in a given market may use Aetna as a TPA and that employer may have exceedingly generous benefits due to collective bargaining agreements, industry practice, or some other reason. Just because Aetna seems to cover a drug under that particular plan, it may not cover the same drug under a different plan, even a plan with the same employer! For example, an employer may have one plan for unionized employees and a different plan with different benefits for non-unionized workers, but both plans are administered by the same TPA. The situation is totally different than plans offered to the general public under the "Obamacare" mandates where coverage and prices are uniform across a state for a particular plan level.
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Post by sellhighdrinklow on Feb 23, 2018 22:18:29 GMT -5
Update- Blue Shield is covering via Prior Authorization and assist from my Dr's Mannkind representative. The pharmacy is different but is now being administered from a local pharmacy via an app. It was a smooth transition, about 24-hours. I'm impressed and happy to be receiving my scheduled 90/4s + 90/8s Thursday! update 2. I jumped the gun. The local pharmacy had the Afrezza prescription in hand but no PA had been approved. The cost with coupon, $650 +/-. (titration pack). Blue Shield, CA not involved (!) Still waiting to get it filled. Not good.
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Post by sellhighdrinklow on Feb 25, 2018 12:21:30 GMT -5
Update- Blue Shield is covering via Prior Authorization and assist from my Dr's Mannkind representative. The pharmacy is different but is now being administered from a local pharmacy via an app. It was a smooth transition, about 24-hours. I'm impressed and happy to be receiving my scheduled 90/4s + 90/8s Thursday! update 2. I jumped the gun. The local pharmacy had the Afrezza prescription in hand but no PA had been approved. The cost with coupon, $650 +/-. (titration pack). Blue Shield, CA not involved (!) Still waiting to get it filled. Not good. I received an automated call from Blue Shield, CA. My Afrezza is now approved via Prior Authorization request. It just took a bit longer than expected.
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Post by thekindaguyiyam on Feb 25, 2018 12:35:58 GMT -5
update 2. I jumped the gun. The local pharmacy had the Afrezza prescription in hand but no PA had been approved. The cost with coupon, $650 +/-. (titration pack). Blue Shield, CA not involved (!) Still waiting to get it filled. Not good. I received an automated call from Blue Shield, CA. My Afrezza is now approved via Prior Authorization request. It just took a bit longer than expected. this is my insurance provider as well. Congratulations. Would appreciate knowing what your copay is. Thanks in advance.
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Post by sellhighdrinklow on Feb 26, 2018 22:50:02 GMT -5
I received an automated call from Blue Shield, CA. My Afrezza is now approved via Prior Authorization request. It just took a bit longer than expected. this is my insurance provider as well. Congratulations. Would appreciate knowing what your copay is. Thanks in advance. My copay was $15 after applying a $55.50 coupon.
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