Ambetter - The AIDS Institute

Ambetter

Link to: Summary of Benefits & Coverage Link to: Formulary

Balanced Care 2 Rx Benefit Design 4-Tier Formulary Deductibles: $6,500 individual $13,000 family 2017

Pharmacy Restrictions: • No Mail Order

Tier

HIV & HCV Rx Placement

T1 Generic

$15 copay

10 HIV 1 HCV

T2 Preferred Brand

$50 copay, PA required

29 HIV

No charge T3 after Non-Preferred deductible, Brand PA required

9 HIV

T4 Specialty

Changes for 2017

CostSharing

No charge after deductible, PA required

Rx Coverage & Restrictions HIV Rx Not Covered: Evotaz Prezcobix Single Tablet Regimens: All 6 covered; 2Rx on T2; 4 Rx on T3 PrEP (Truvada): T2, PA

1 HIV 11 HCV

• Added PA for T2 (does not apply to HIV Rx except Truvada)

Review of 2017 Florida Silver Qualified Health Plans January 2017

Hepatitis C Direct Acting Antivirals Not Covered: Olysio Technivie Veikira Pak Viekira Pak XR Zepatier PA: All 12 Rx

FOIR HIV Rx Safe Harbor Compliance: Yes, but cost-sharing caps do not apply before deductible is met on T3 & T4 • Added Genvoya, Odefsey, Triumeq, • Added Daklinza & Vitekta, and branded Epclusa Combivir, Epivir, Trizivir Key Red indicates unfavorable changes from 2016 DED – Deductible MO – Mail Order PA – Prior Authorization QL – Quantity Limit

Florida Blue


Blue Select Silver 1443 Rx Benefit Design

2017

Tier

CostSharing


7-Tier Formulary

T1 Preventive

No charge

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Deductibles: • $6,500 individual • $13,000 family • Applies to Rx on Tiers 3, 5, 6, 7 Pharmacy Restrictions: • Rx not covered outof-network • Brand Rx: 30-day retail supply; 90day MO supply at 2.5x retail amount • Specialty Rx: No Mail Order

T2 Condition Care Generic

$5

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T3 All Other Generic

DED + $31

T4 Condition Care Brand

$35

9 HIV

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T5 DED + $65 Preferred Brand

35 HIV

T6 Non-Preferred Brand

9 HIV

DED + 50% coinsurance

T7 Specialty DED + 50% Generic & Brand coinsurance

1 HIV 14 HCV

• Added 3 tiers • Increased Changes • Increased copays deductibles for 2017 • Introduced coinsurance • Offering Mail Order discount Review of 2017 Florida Silver Qualified Health Plans February 2017

Rx Coverage & Restrictions HIV Single Tablet Regimens: All 6 covered on T5 PrEP (Truvada): T5, PA, QL

Hepatitis C Direct Acting Antivirals: All 9 covered with PA & QL PA: 13 of 14 Rx

PA & QL: All brand HIV Rx

FOIR HIV Rx Safe Harbor Compliance: Yes but not clearly indicated for tiers with coinsurance & caps do not apply before deductible is met. • Added PA for all brand HIV Rx (10/2015) • Added Descovy, Genvoya, Odefsey

• Added Daklinza, Epclusa, Technivie, Zepatier

Key Red indicates unfavorable changes from 2016 DED – Deductible MO – Mail Order PA – Prior Authorization QL – Quantity Limit

Florida Blue HMO


MyBlue Silver 1604

Rx Benefit Design

2017

Tier

CostSharing


6-Tier Formulary

T1 Preventive

No charge

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Deductibles: • $6,500 individual • $13,000 family Pharmacy Restrictions: • Rx not covered out-of-network • Brand Rx: 30-day retail supply; 90day MO supply at 2.5x retail amount • Specialty Rx: No Mail Order

T2 Condition Care Generic

$4

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Changes • Increased for 2017 deductibles

T3 Low-Cost Generic

DED + $25

T4 Condition Care Brand

$30

T5 High-Cost Generic, Preferred Brand

DED + $55

T6 Specialty DED + 50% Generic & Brand, coinsurance Nonpreferred

1 HIV

-45 HIV

1 HIV 8 HCV

• Added coverage of nonpreferred • Decreased copay for T3 • Increased copay/coinsurance for T5 & T6


Rx Coverage & Restrictions HIV Single Tablet Regimens: All 6 covered on T5 PrEP (Truvada): T5, PA, QL PA & QL: All brand HIV Rx FOIR HIV Rx Safe Harbor Compliance: Yes but not clearly indicated for tiers with coinsurance & caps do not apply before deductible is met.

Hepatitis C Direct Acting Antivirals Not Covered: Olysio Technivie Viekira Pak Viekira Pak XR Zepatier PA & QL: 7 of 8 Rx

• Added Descovy, Genvoya, Odefsey


Florida Health Care


FHCP IND Essential Plus Silver POS 54 Rx Benefit Design 7-Tier Formulary

2017

Deductibles: In-Network • $2,500 Individual • $5,000 Family Out-of-Network • $5,000 Individual • $10,000 Family

Tier


T1 Preferred Generic

$3

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T2 Nonpreferred Generic

$10

9 HIV 1 HCV

T3 Preferred Brand DED + $30 T4 Nonpreferred Brand

Pharmacy Restrictions: • T1-T4: must use FHCP & select in-network T5 Specialty Walgreens pharms. • When PA or ST required, must use T6 Self-Injected FCHP pharms. • 93-day MO supply T7 Preventive OTC through FHCP Changes for 2017

CostSharing

33 HIV

DED + $55

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DED + 50% Coinsurance; FHCP pharm only; no MO

9 HCV

Not Listed

1 HCV

$0

HIV

Hepatitis C

Rx Not Covered: Tybost

Direct Acting Antivirals NOT covered: Single Tablet Daklinza Regimens: All 6 covered on T3 Epclusa Harvoni Olysio PrEP (Truvada): T3 PA: 6 of 11 Rx FOIR HIV Rx Safe Harbor Compliance: Yes, but costsharing caps do not apply before deductible is met.

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• Higher Deductibles & • Increased coinsurance for T5 from 20% to added out-of-network 50% deductible • Exempted T1 & T2 from deductible • Added preventive tier • Added pharmacy restrictions Review of 2017 Florida Silver Qualified Health Plans April 2017

Rx Coverage & Restrictions

• Added Descovy, • Added Sovaldi & Genvoya, Odefsey, Technivie Triumeq Key Red indicates unfavorable changes from 2016 DED – Deductible MO – Mail Order PA – Prior Authorization QL – Quantity Limit

Health First


Silver POS 70 1311 Rx Benefit Design 5-Tier Formulary

2017

Deductibles: In-Network • $3,500 individual • $7,000 family Out-of-Network • $7,000 individual • 14,000 family Rx • $500 individual • $1000 family

Tier T1 Preferred Generic

Cost-Sharing


$2 HIV SH $40

7 HIV

T2 $15 Nonpreferred HIV SH $55 Generic

1 HIV

T3 Preferred Brand

36 HIV

$30 + DED HIV SH $70

T4 $50 + DED Nonpreferred HIV SH $150 Brand

Pharmacy Restrictions: All copays are for 30day supplies, retail or T5 Specialty Mail Order

30% coinsurance + DED HIV SH $200

7 HIV 1 HCV

Rx Coverage & Restrictions HIV Single Tablet Regimens: All 6 covered on T3, SH PrEP (Truvada): T3, SH

Hepatitis C Direct Acting Antivirals Not Covered: Epculsa Technivie Viekira Pak Viekira Pak XR Zepatier

FOIR HIV Rx Safe Harbor Compliance: PA: All 8 Rx Yes. Cost-sharing limits designated by “SH”.

1 HIV 7 HCV

• Added out-ofnetwork & Rx Changes deductibles for 2017

• Added Descovy, • Added Harvoni & Evotaz, Genvoya, Sovaldi Odefsey, Prezcobiz, • Removed Technivie Triumeq, Tybost, Vitekta Review of 2017 Florida Silver Qualified Health Plans January 2017

Key Red indicates unfavorable changes from 2016 DED – Deductible MO – Mail Order SH – HIV Rx Safe Harbor Cost-Sharing Limit Applies

Humana


Silver 3550/South Florida HUMx (HMOx) Rx Benefit Design 5-Tier Formulary

2017

Deductibles: • $3,550 individual • $7,100 family Rx • $500 individual • $1,000 family Pharmacy Restrictions: • PA may be required, penalty will be 100% for certain Rx • MO not available for specialty • Limited Distribution Rx may not be available at all innetwork pharmacies

Tier

Cost-Sharing


$10 retail, $25 MO 90 HIV CM1 $40

7 HIV

$20 retail, $50 MO T2 Nonpreferred 90 Generic HIV CM1 $40

2 HIV 1 HCV

$50 retail, $125 MO 90 DED applies HIV CM2 $70

31 HIV 1 HCV

T1 Preferred Generic

T3 Preferred Brand

T4 Nonpreferred 50% after DED Brand HIV CM3 $150

T5 Specialty

40% pref. pharmacy, 50% nonpref. after DED HIV CM4 $200

• Added Rx Deductible • Exempted T1 & T2 from deductible • Eliminated MO for specialty Changes • Added PA penalty • Added limited for 2017 distribution restriction Review of 2017 Florida Silver Qualified Health Plans April 2017

6 HIV

7 HIV 8 HCV

Rx Coverage & Restrictions HIV

Hepatitis C

Single Tablet Direct Acting Regimens: Antivirals Not All 6 covered; 5 on Covered: T3; 1 on T5; HIV Olysio Cost-Share Technivie Maximum not Viekira Pak applied to Genvoya Viekria Pak XR or Odefsey Zepatier PrEP (Truvada): T3, PA: 8 of 10 Rx QL, SP, CM2 FOIR HIV Rx Safe Harbor Compliance: Yes. Cost-sharing limits designated by “CM”. • Added Descovy, • Added Genvoya, Odefsey Daklinza

Key Red indicates unfavorable changes from 2016 DED – Deductible MO – Mail Order CM – HIV Cost-Share Maximum PA – Prior Authorization

Molina


Marketplace Silver 250 Rx Benefit Design 5-Tier Formulary

2017

Deductibles: • $2,400 Individual • $4,800 Family Rx exempt from DED Pharmacy Restrictions: T1-T3: 2x cost-sharing for 90 day Mail Order

Tier

CostSharing

T1 Generic

$10

9 HIV

T2 Preferred Brand

$55

29 HIV

T3 40% Nonpreferred coinsurance Brand retail

T4 Specialty

40% coinsurance

T5 Preventive No charge; Drugs MO available

• Increased deductibles Changes • Exempted all Rx from for 2017 deductible • Added Preventive Tier


-2 HIV 10 HCV

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• Increased T3 & T4 coinsurance from 30% to 40%


Rx Coverage & Restrictions HIV Rx Not Covered: Descovy Odefsey Videx EC

Single Tablet Regimens: 5 of the 6 covered on T2

Hepatitis C Direct Acting Antivirals Not Covered: Epclusa Olysio Viekria Pak XR PA: All 10 Rx

PrEP (Truvada): T2

FOIR HIV Rx Safe Harbor Compliance: Yes for most Rx; no cost-sharing caps indicated for 2 Rx subject to coinsurance • Added Genvoya • Removed branded Epivir

• Added Daklinza, Technivie, Zepatier
