Friday, January 20, 2017

Auvi-Q Coverage Details

Disclaimer: This post contains information that I am providing to the best of my knowledge. Many details are currently still in flux and information may change. Ultimately, your insurer and/or kaléo will be your best source for final clarification and this information is provided as a courtesy to help navigate the often muddy waters of insurance coverage.

In my previous post, I provided information on Auvi-Q's upcoming re-launch. Please read that post, first, for an overview. Also please make sure to read the FAQ provided by kaléo. This post will deal with additional details and questions that have arisen.
  • What about those on government insurance plans, such as Medicare, Medicaid, and Tricare?
    • Those details are still being finalized. Government-sponsored plans vary widely in their coverage of prescription medications. 
    • Though not yet confirmed, co-pays for those on government-sponsored plans are expected to be $50 or less. There are several providers of government plans, each with their own coverage details. The expectation is that they will provide coverage, but the co-pay would vary based on various factors like formulary tiers, preferred status designations, etc.
    • There is a reasonable expectation that the Auvi-Q will be covered by Tricare, but various details are still being resolved.
    • By law, kaléo is not allowed to cover/subsidize the co-pay for patients on government insurance plans. In any event, they are working hard to ensure that everyone who wants the Auvi-Q will be able to get it as an affordable price.
  • Will insurance companies cover the Auvi-Q, given the high list price? (This topic is covered in more detail under a separate post.)
    • The Auvi-Q is an innovative, brand-name device. It's relatively new to the epinephrine auto-injector (EAI) market. It's the only talking EAI on the market. A talking EAI can be comforting and helpful for those in a high-stress situation, and/or those with no previous experience with EAIs. Its compact size makes it preferable for many teens who like to carry their devices without calling undue attention to themselves. Various insurers may see the benefits of such a device to patients and choose to provide coverage for the Auvi-Q. 
    • For those with commercial insurance, whose insurance companies do not provide Auvi-Q coverage, kaléo will absorb those costs and patients will pay $0. Those with commercial insurance are not subject to the annual household income limits. That only pertains to those without any commercial or government insurance. 
  • How can I find out of my insurance plan will cover the Auvi-Q?
    • If you have commercial insurance, you can proceed straight to your doctor with the Direct Delivery forms, which they can submit to Kaléo. Kaléo and their partners will take care of finding out coverage details. If it's covered - you get it for $0. If it's not covered - you get it for $0.
    • You can try to contact your provider to see if they have information, but some plans are still finalizing details. 
    • To reiterate an important point, if you have commercial insurance (as around 200 million in the U.S. do) even if your formulary does not include the Auvi-Q, it will still be $0.
  • Is this a limited-time offer?
    • No, this is not a coupon, or a limited-time offer. This is their pricing model for the foreseeable future and there is no set time limit. 
  • How many sets can I get?
    • You can get up to 3 cartons per prescription, twice a year, for a total of 6 cartons per year. This applies both to sets obtained through the pharmacy and through direct purchase. 
    • Update: Due to high demand, there may currently be a limit of one set per month. Priority may also be given to those fulfilling prescriptions for the first time and newly-diagnosed. 

Have more questions? Please let me know!

Update 2/7/2017: We had an allergist appointment on 2/4 and I submitted the form for direct delivery to our allergist. The allergist's office submitted it to see if it could be processed ahead of the 2/14 release date and it was processed, today! I just received a call and was told that my prescription was processed. Premier Specialty is the pharmacy that will be handling my prescription (I am guessing this can vary by state/plan.) They checked to see if the Auvi-Q is covered by my insurance (I have Highmark Blue Cross/Blue Shield with CVS/Caremark for prescriptions) and they said it IS covered, with a $45 co-pay. They said kaléo is covering the $45, so it will be $0 to me. It will be shipped out on 2/14 and should arrive within 48 hours. I was asked if I wanted to sign for it, but I declined. I am usually home, but don't want to miss the delivery. They also offered to let me speak with a clinician or a nurse about the medication, but I declined, as I am familiar with epinephrine and the Auvi-Q, itself.

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