78 Comments
Has your insurance company ever denied your T1D medications or supplies? Share more in the comments about how you navigated this process.
You must be logged in to post a comment.
© 2023 T1D Exchange. All Rights Reserved.
YES, SEVERAL BP meds in the past, but my doctor had to write a letter to them and they got approved but sometimes at a very high price..
I was originally denied a Continuous Glucose Monitor (CGM) back in, I think it was, 2006. CGM’s were new, and my insurance company had not yet approved them. After, I fell from a low blood glucose, and fractured my ankle in the fall, I telephoned an insurance agent and told them that I may not be home from work with a cast on my leg if I’d have had a CGM. Very soon afterward, I was approved to have a CGM. I may have been the first person approved for a CGM by my insurance company.
Not supplies but the first time I tried to get a CGM they did I had to go through the denial process with all kinds of letters from my doctor, etc. finally they paid.
When United Health Care decided to only cover Medtronic pumps. I had just purchased a Tandem pump on my previous policy. They would not cover my supplies. I had to MDI for a year until that policy was reversed.
I wanted Afrezza for when I fly and have to remove my pod but the insurance denied it. If I don’t remove the pod, I go below 30 for the entire flight no matter how many carbs I take. Nothing I could do to get an override so I just make do.
My insulin has been denied before and currently my omnipod 5 pods are being denied even though they were covered last year
My Omnipods and G7s have to get approval every year, but they always have approved them. The doctor says I need them and they get approved very quickly.
I selected other. I was not denied but was limited on insulin and pump cartridges and infusion sets for the 30 day supply that needed Medicare approval. I had to go through 2 cycles of getting my PA to send new Rx scrips for 2 months to get enough. On top of that it is a 30 day (Dexcom G7) or 90 day supply (insulin, infusion sets and cartridges). It’s also not a 1 month or 3 month supply. What does Medicare people think? We’re selling off surplus supplies? I mean, really!?!
I had to use the insulin they covered; I had to order my CGM supplies Byram only, and they only covered Libre not Dexcom or others.
I was able to get the Omnipod 5 Starter Kit after going through prior approval. But when the time came to get my first order of Pods, they were again denied and I had to go through prior approval a second time. And of course the second time the insurer said they never got the notification, while my doctor said they sent it. I had to switch to my old pump before it got resolved.
Yes, for a CGM in 2018. The insurance medical director said my diabetes wasn’t bad enough; I needed an A1C above 6. The insurance eventually covered the CGM after going through the denial appeal, letters from my doctor, etc. I think this is a common practice for the insurance companies to save money, delaying care until their hand is forced.
Had to have my endo send a note to continue using Lantus, multiple times…and they charged extra. Eventually it just was easier to switch to basaglar. Never had an issue with my bolus
Yes but I applied to get special permission to keep what I was using and they have let me. It was my long acting insulin and my test strips.
Aetna/Medicare denied Humalog insulin a few years ap. They insisted I use Novolog, which did not work well for me. My endo got permission for me to resume using Humalog, I received a letter from Aetna/Medicare (?) giving me permission.
For two years now I am using One Touch Verio test strips. For many previous years I used Freestyle Lite strips. The Freestyle strips are more highly rated. They give me numbers that correspond yo the way I feel. One Touch frequently does not agree with my feelings of my blood sugar level.
Question for you Richard, does your One Touch read higher than actual? I have chronic anemia – have been anemic my entire life. The One Touch has been shown to read higher – and at times very much so – than actual on people with anemia. Back in the day when the protocol was to do a confirmation fingerstick when the CGM alerted to a low/pending low, I would do the fingerstick and the meter would read 150, 180+. Of course that meant a correction bolus – the last thing I needed. I would crash, and often EMS would be required. By luck I got on the invite list for Endo CME and one of the topics was home monitor accuracy/inaccuracy issues. Learned about the One Touch and after reading the hard copies of the reports I switched to the Bayer Next. No crashes in 6-7 years now. I pay out of pocket, but I don’t do that many fingersticks anyway anymore
What.a great question! Yes, they denied my insulin pump and supplies because I was too controlled. My A1C on the pump was 5.8 – 6.0 over 5 years. When I switched insurance, they said I wasn’t diabetic enough to warrant a pump. I need to be out of control to qualify. Hahaha! My Endo got involved spoke to the insurance company and sent them all my records. They finally came to Jesus when he showed them that I reason I was so well controlled was the pump itself and I was allergic to long acting NPH.
The exact same thing happened to me! I’ve been a T1 for over 50 years, have a great A1c BECAUSE of the pump and A1c and they denied me because of it. I appealed, they denied again. My endocrinologist reported them to my state medical association and they finally had to approve it. And to make matters worse, the doctor who determined that I didn’t need the pump and CGM was a sports medicine doc—not an endocrinologist.
When a treatment-medicine is new, insurance tries to claim it is still being investigated and is awaiting approval. NONSENSE! If it’s available at a pharmacy, it has completed approval. Over the years, that insurance excuse has morphed into a requirement for a “prior authorization.” HUH?! Why do my doctor and I have to explain why it’s necessary. The prescription is evidence of the doctor’s thinking it’s necessary. My presenting the prescription shows I agree with the doctor. Why go through multiple questions proving it’s necessary as part of prior authorization. Big pharma, huge insurance, corporate medicine are all big money rackets who have no interest in my health, yet have extreme interest in saving a nickel.
You absolutely nailed it!
Just had Novolog ‘un’covered, sent an appeal with documentation from Tandem and got it covered.
With the prices some supplies and meds cost they might as well deny getting them!
-Grim Laughter- As a T1, 3 strips per day is what they cover period. Unable to afford CGM tech… is that “denial” or something far, far more lethal??? Let’s see, one test per meal… ok fine. Ooopse, NO testing before bed for me!!! Before we get behind the wheel…. ENNNDH, NO testing allowed. Two hours after meals to check if the coverage was right…. ENNNGH, NO. Testing if I’m crashing, NO… sorry cannot do any of those MANDATORY things, you can have a grand total of three (3) strips period, as a Type 1 diabetic, hard stop. YEAH, I have been denied with deliberate, and entirely malevolent intent. They refuse to allow any backup of CGM sensors… refuse to allow extra backup of long or short acting insulin. If it gets lost, goes out of date, starts acting wonky, you have zero backup to use. Sorry you are screwed… but…I’m only looking for an extra vial/pen for literal emergencies ….. TOO BAD, nothing extra to guarantee you are safe. YEAH I HAVE BEEN DENIED.
I was just denied Humalog and has to use a generic Novolog. In 2007 my insurance at that time denied all insulin, pump, cgm. Because I couldn’t be T1D with and A1c of 5.0 I had to file a complaint with Washington State Insurance Commission. I had to pay full price for insulin, when into DKA, until I got resolved.
Just infuriating.
Medicare denied my strips initially because I used a CGM. That got resolved after an appeal and much time, but then they would not send them until I sent info that I had purchased a meter! OMG – SO frustrating. Now, I am not able to get strips because for some reason my Medicare number was changed?? Lots of time on the phone yesterday and it is still not resolved.
Two instances come to mind.One was pre-Medicare and the other was post-Medicare. I was dx’d Type 1 in 1976 and began using insulin at that time. Pre-Medicare, I was using one vial of NPH/month with a 90 prescription for 3 vials of insulin to be used in my insulin pump. Medco, the PBM for my insurer, only sent me 2 vials. When I called to question the reduction from the RX and excalated to a “Diabetes Specialist”, I was told that based on the number of units used per day, the total number of units in 2 vials would cover me for 3 months. The “specialist” was under the impression that an insulin pump reservoir/cartridge would accept the entire contents of one 10ml insulin vial (10ml=1000u) and be used until it was empty. I again had to escalate to a supervisor to explain about infusion site change frequency and allowances for unused insulin due to tube fill, ullage and variable factors in daily use (illness etc). When I threatened to send a complaint letter to their home office along with a copy to our state’s insurance department, I received my third vial. The next event happened immediately after I became eligible for Medicare. Because I was using insulin in an insulin pump, Medicare covers my insulin under Medicare Part B vs Medicare Part D. The Medicare requirements for insulin coverage under Part B require that the RX be written differently than when covered under Part D. The Part B RX must note 3 specific items not required under Medicare Part D insulin coverage.: 1- The ICD code for my specific type of diabetes; 2- The statement that it is used in an insulin pump; 3- The specific number of units that I must use per day. I had to educate my endo about these Medicare RX requirements which I learned of when I questioned the denial of my insulin. My provider then was Publix Pharmacy. In the spring of 2015, Publix sent me a letter advising that they would no longer cover insulin RX under Medicare Part B because of the difficulty in obtaining Medicare reimbursement. I was lucky enough to find a Walmart near me that has since been handling my insulin RX. It also took me 18-months to get Medicare to cover more than 3 test strips per day. (I did not begin using a CGM until 2019 and had been testing 8 times per day to maintain good control.) I undertook appeals of the Medicare denials myself (after my endo and pharmacy got no results) and was prepared for the 4th and final appeal before a Medicare judge when Medicare “redetermined” their denials and covered the 8 test strips I required. The denials had been primarily due to my endo’s clinical case notes NOT covering the items required by Medicare to override their stated norm of 3 test strips per day for insulin-dependent diabetics. I, once again, educated my endo about what his case notes had to include in order for me to obtain 8 test strips per day.
I live in the UK (United Kingdom of Great Britain and Northern Ireland) where ALL of my diabetes-related supplies are paid for via our NHS (National Health Service), which is financed via direct taxation of all working people that earn above a threshold point. I, therefore, don’t have a problem with medications or supplies being denied.
True, but only if they are on the approved list.
We lived in the UK from 1991 to 2006. Pumps were not covered then. After I left, they first only covered them for children, and now do for everyone. I was in my 50’s when we left the UK and moved back to the U.S. We immediately signed up for the most expensive health insurance at my husband’s company so I would be able to get a pump immediately at a lower cost. After that I started working and had to use the insurance my own company provided. They would tell me which insulin I had to use, and it would change. That was fine. Then when I needed my first CGM due to hypoglycemic unawareness, it was denied. I phoned the insurance company to ask why and she hinted that there were only two things that could be used to appeal the decision, one of which was hypoglycemic unawareness. So I told the doctor, he appealed, and I have been covered for CGM’s ever since. On Medicare, I knew that pump users had to get insulin using Part B, not Part D. I went to CVS, because the pump supplier did not offer insulin at that time. They knew how to bill it correctly, but it was denied twice. They were not giving enough information. I figured out what was needed and phoned their billing department to tell them they needed a dated receipt showing I already owned a pump, since I had gotten the pump on my previous insurance. The person at CVS said they just needed the date of purchase, which I gave them. The insulin was denied yet again. So I looked on the Medicare site to see what they really needed, and I did an appeal myself, sending a copy of the receipt for the pump and some other stuff, including the fact they were already covering my pump supplies, and had been for 9 months already. That worked, but it took so long that the original denial was over 1 year old and could not be paid retroactively. CVS never charged me for that. I was worried that after two denials they would not provide the insulin for free, but they said they would because they knew it was covered.
I have to add that insulin, syringes and test strips (and urine tests) were never covered by insurance before we moved to the UK in 1991, so it was a pleasant surprise to have the coverage when we returned. But after insurance companies started paying, the manufacturers were able to raise prices a lot more because insurance companies could afford higher prices than individuals. This is one reason health care costs are so high in our country.
@KSannie.
I ‘hear’ what you say, ma’am. I’ve been using a pump since 1990, but I was the first person, in the area that I live, to have been ‘granted this permission’. (My endocrinologist had to write to NICE (National Institute for Clinical Excellence) justifying the expense. He did this, apparently, by stating how much it was costing to keep me in hospital, as I used to spend almost as much time in hospital as I was at home.)
I’m afraid it’s not quite as simple as saying that everyone that’s diabetic can have a pump. That’s NOT the case … unless they self-fund them. Although NICE state that pumps SHOULD be made available for diabetic patients, Local NHS Trusts still have to justify how much it would cost to supply the pump and related paraphernalia when compared to the cost of MDI (Multiple Daily Injections). Of course, it helps if you’ve got a Diabetes Support Team that agree that the patient’s health would benefit from the switch to pump technology. (Sadly, some diabetic patients are under the impression that with pump technology they could ‘go back to doing whatever they want’. I was requested by my Diabetes Support Team to speak with a guy that was an in-patient at my local hospital. He was adamant that he didn’t need to ‘do a course’ on carb counting as he’d been diabetic for so many years, then he tried to convince me that there were no carbs in potatoes. 😉 ) His language was more than colourful [colorful] in that he stated he’d asked about a pump a few years beforehand, but that they kept denying him that option. I advised him that the MOST PROBABLE cause was because of his belief that there were no carbs in potatoes and his refusal to attend a course … over here it’s called DAfNE (Dose Adjustment for Normal Eating). I’m afraid I don’t know if he ever was able to convince his Diabetes Support Team to allay their fears and ‘put his name forward’ in order to get a pump.
I’m so sorry that your own company insurance were able to tell you which specific insulin they would cover. Sadly, that tends to be a problem when people THINK they know better than your doctor/endocrinologist as to which insulin type would be most beneficial to YOUR diabetes control.
Even after I started using a pump, and was still being admitted to hospital with severe hypoglycaemic [hypoglycemic] events, even when it was known that I was already suffering with severe hypoglycaemic [hypoglycemic] unawareness, it took several years before I gained access to CGM metering that could ‘talk’ directly to my pump. (I was tried with other methods, such as FreeStyle Libre … the first generation, but that proved useless. It’s NOT CGM (Continuous Glucose Monitoring) but rather FGM (Flash Glucose Monitoring), meaning that it only gives you an ‘accurate’ reading when you swipe it with your phone or a reader. Unfortunately, by the time I had any warning that my blood glucose level was low, it was too late as I used to aleady be unconscious.)
I’m pleased that you were able to ‘get things sorted’ when you appealed the decisions being made that denied your access to CGMs.
Sadly, test strips are still not prescribed to Type 2 Diabetics. The general attitude from doctors and nurses is that there is no need to test, and that many diabetics that have had them prescribed in the past, over test. i.e. that in some way they test too frequently. They’re lucky if they can get their doctor to test their HbA1c every 3 months. (I’ve signed petitions on a number of occasions to our Government, requesting them to look at the inefficiency of type 2 diabetics going on to develop diabetes-related complications simply because they aren’t aware of what their blood glucose levels are doing.) Obviously, not all doctors and nurses agree with this standpoint, but they have to agree with whaterver NICE (National Institute for Clinical Excellence) state, or risk losing their funding.
Unfortunately, I do know about the exhorbitant pricing for diabetes care in the United States of America, having ‘lost’ several friends that have ‘passed over’ through not being able to financially cover these costs. (I’ve been contacted by family and friends when former ‘internet friends’ have passed over, stating that they were unable to afford insulin, etc. That’s a sad indictment on policies over there, where they can spend billions of dollars on weapons and the like, yet let people in need die. )
I wish you the very best of health, ma’am, for now and all time, and I thank you for replying to my original post.
@John McHenery,
Yes, sir, I ‘hear’ what you say. I suppose that SOMEONE has the job of ‘sorting out’ what THEY believe would be of most benefit to the many, based on their limited beliefs, rather than looking at individual cases.
Other, as my medicines and supplies come through the UK National Health Service. That said, if their committee has decided that medicines or supplies are not to go the approved list then you have to pay for them if you want them.
Not current insurance, but past ones have, especially back in the days of pre-existing condition clauses.
My test strips are not covered, as of now, but because of my CGM the only times I test are to calibrate, so I just buy them out of pocket.
I was in seeing a née dr when my sensor went bad. The new Dr didn’t have my records of me using a sensor for several years. I was going on vacation where there was a time difference and I needed the sensor desperately. I ended up purchasing one out of pockets. It surely hurt the budget that month
Yes , ny supplier is shorting me on sensors e.g. My last expires two days before I get the next 90 days supply. I’m going to have to purchase some myself to get continuous monitoring.
Medicare will not cover test strips and lancets if you have a CGM because the CGM makers claim that you never have fingerstick ever again!
Which we all as users know is completely false!
Yes these are all self pay. I wonder if now that my CGM is telling me to calibrate, we couldn’t appeal this.
Not true if you have Rx for the additional strip. This is a phamacy fail because it’s covered if billed correctly. This was attempted years ago and this limit is no longer in the Medicare coverage.
I have denied coverage for all of my diabetes needs, including insulin. I had either had to go through an appeal process or get another round of preauthorization. For my insulin pump it was a six month process. Most recently it has been yry to find an insulin provider for Medicare Part B. It is always a stressful process when insurance providers think they know better than your doctor.
It was years ago when I was using the DexCom G3. It had been covered for about a year and a half. Then the insurance company denied coverage. My Endo helped me write an appeal letter. After that, my CGM has been covered.
Not straight out denied, but required a PA.
You need to first know what your insurance “prefers” you to be on… usually it’s the one that costs them the least. Then you have to “try and fail” on that product. For diabetes.. try and fail almost always fall under these 3 events: Patterns of Hypoglycemia, Hyperglycemia, Lipohypertrohy (scare tissue).
Then you have to pray they listen because nobody really holds them accountable.
Never denied but required me to switch from Humalog to Novalog insulin
Tech no, yet on Medicare receiving Dexcom b4 final switch to 780G. Tried to renew to G8, denied. Control much better monitoring 2 CGM’s. 1 much better catching low’s the other capturing high values
It denied me glucagon. Charged $635 dollars out of pocket, I spent hours trying to get it covered. They refused.
They won’t cover back up test strips, syringes or back up long acting insulin because I am a pump and Dexcom. there is no work around that I found.
not as pricy, but alcohol swabs, batteries and glucose aren’t covered either. Glucose tabs for some reason got really expensive in the last few years… or maybe that’s on me, I used to use skittles and those were never covered 🙂
There is also the cost of our time, having to constantly pursue insurance companies.
You are correct saying that the cost of glucose tablets went up. They have practically doubled in price in the last year or two. I used to buy them but now use smarties, jelly beans, sweet tarts or other such candies.
The day I was diagnosed, my biggest worry was the amount of time and energy I’d have to spend getting what I needed from the healthcare system to stay healthy. My most memorable denial happened when I tried to get my first pump in 1998. I was told that if I couldn’t use my fingers or toes to give myself injections, they would send a nurse to my house every day because that would be less expensive than a pump. That was a pretty stark indication that their priority was $$, not my quality of life. I’ve experienced many more mysterious and/or short-sighted denials over the years. Fortunately, my employers’ HR people were happy to step in to reverse denials because they knew that it was in their best interest to keep me healthy enough to work. I’m grateful for having a healthy and productive life, but I have to say that the stress and wasted time from dealing with our crazy healthcare system affects my quality of life more than the disease itself.
Several times the insulin brand was denied and switched to a different brand. Also, when I switched to Afrezza, the authorization was initially denied. With help from Mannkind, it was finally approved. When I switched from insurance to Medicare, I went straight to Mannkind who helped me get authorization with the prescription plan.
Good to know about Afrezza. Thanks.
I answered other, because they have always provided supplies they deemed medically necessary, insulin, syringes, test strips. They, however did not deem CGMs or pumps medically necessary and therefore would not provide them. It was hard to argue that those items were medically NECESSARY as I have managed without them since 1970.
Last year my primary insurance very suddenly, no notification, started requiring prior approval for the Dexcom 6 sensors and transmitters that I was ordering from a DME supplier. At the same time, primary insurance stopped covering CGMs as DME and switched coverage to pharmacy. Since I wasn’t notified of the change by either the insurance company or the DME supplier, I continued to request the CGM supplies on a monthly basis to comply with Medicare, my secondary insurance. I got stuck with 3 months of 0 coverage for Dexcom G6 supplies because of that.
Not denied, but they want to charge me $500 for a pump because of my Medicare Part D deductible. So I’m unenrolling from D so it will be free under B.
My endocrinologist didn’t code a blood test properly, and it took forever to get it straightened out and I ended up having to pay for it because I went too long for the claim. Now I know.
When CGM’s first came out Medicare would not cover them for a couple years. The eventually approved them effective Jan but there process wasn’t in place. So when I got one in Jan. I was denied. I’d paid for it my self expecting they’d get straightened around and reimburse me. Well I had to appeal up to an administrative law judge who ruled in my favor and I got reimbursed for some of it.
Yes. Once Dr’s prescription was entered wrong at their office. Insulin was down to last drop before fixed.
Switching from our insurance to Medicare was a laps in services. We paid insurance to cover the gap. Company took our premiums monthly, then after a time we were denied coverage and told we had to pay past bills ourselves. 9 months of bills, including some diabetes totaling $80,000. Our lawyer referred us to legal office specializing in insurance disputes. Since my husband had email from insurance co and they had taken all monthly premiums they were obligated to honor their agreement. It was a mess having them pay back what we did in cash. It did all start with being told I didn’t need to sign up for medicare from their office. Our insurance denied coverage because I was Medicare eligible. But they had entered into agreement for extension. Very scary time full of worry. Felt so bad paying for diabetes supplies completely on my own. Grateful we were reimbursed in the end.
For Rx, Gvoke for 3 months activated mfg savings card and paid, sensors for Medtronic Guardian sensors while on 670G closed loop pump – moved to Dexcom G6 sensor and then when warranty was up, switched pumps to Tandem X2 pump with Control IQ.
In January, I was denied Afrezza because my A1c was “good enough.” It reminds me of years ago when I was limited to 4 test strips a day. I had wanted to test before driving in addition to my mealtimes and bed time. That was not a good enough reason.
Insurance companies (and some Endo’s: penny wise and pound foolish) When will insurance companies realize that a little expenditure (and it is a lot smaller than what we would pay if paying out of pocket – they get everything wholesale) for supplies etc will save them big $$ later – fewer visits to the Emergency Dept – that sort of thing.
I had an Endo complain about the number of strips I wanted Rx’d. I answered his question with a question. I asked about his experience during residency rotation – was he ever “on scene” for vehicle accidents caused by impaired driver(s). He scoffed at the idea. I told him I’ve lost count of those incidents and I check (pre-CGM days) with a fingerstick every time I am going to drive. I told him I was doing my small part in making our roads and freeways safer – for everyone, including him.
When I first started on the pump, over 20 years ago. The insurance company covered the cost of the pump but denied supplies. Got my brother-in-law (who is an attorney) on a conference call. He informed them that he was taping the call. Went over the facts, the pump was covered and the supplies were not covered. After going up several levels they finally approved it.
As you’ve probably noticed, I’ve made several comments on this question. My concern about AI in insurance decision-making on claims has gotten bigger. Insurance companies often decide how much of an Rx a person needs, often allowing only 30 days worth (according to their calculations). Prior Authorizations for insulin refills etc.
Shylock was a Shakespearean character of 500 years ago demanding his pound of flesh. He is alive and well brilliantly disguised in suits, ties, and pant suits as Insurance, pharmacies, hospitals, drug stores, middle men, and perhaps worst of all . . . politicians. Sigh!
I was excited about trying the eversense 6 month CGM. Insurance seen it as a trial device so would cover it or the insertion procedure. I found this out from my Endo and their sales rep two days before my scheduled procedure. I had to threaten the pharmacy and the two with turning it into a fraudulent charge to get my money back in the sensor.
Would NOT cover …
The only prescription my insurance denied was for Afrezza. My diabetes PA reapplied for the prescription and it went through. I am not sure what she changed when ordering it for me.
I believe she contacted the makers of afrezza to get the ball rolling.
Never had a problem until I went on Medicare last October. I had trouble getting enough test strips-I test 6 times per day at least. The Endo said they needed something from the pharmacy and the pharmacy said the Endo should get the bar coded form from Medicare. I literally went back and forth between them and told them their pointing at each other was doing ME THE CUSTOMER no good. Then, Medtronic wouldn’t send me my supplies. Medicare required C peptide test. Had that. Then Medtronic said my C-Peptide at .5 was TOO GOOD for me to get supplies. I said I don’t know what you are looking at but my test results say .19! Then they said well your creatinine and EDGR or FR was too good. I said: you mean to tell me that my kidneys have to be failing before I can get pump supplies for insulin??!! I asked to speak to a supervisor and said this sounds to me like you or Medicare are trying to stall until Jan 1 when deductible is required again. I said I’ve been trying to get this resolved since the beginning of December. She said -please hold. She came back in the phone and said my supplies were in delivery. What the heck is going on??!! It’s enough for me to ALMOST go back to work. I spent 2 hours on the phone. I think the reason we have to stop work is so we have enough time for all the bull we are put through when we go to Medicare.
Just wow. I am considering retiring and this kind of thing scares the sfgk out of me.
James,
Didn’t mean to scare you but just leave plenty of time to deal with the issues. Don’t wait until you absolutely need something before ordering. Retirement is great and you do have loads of time to work through it. Just don’t take no for an answer. Fight for what you need. I hate that EVERYTHING seems to be a fight these days but I tell people I WILL NOT give up fighting for myself.
My doctor gave me a script for Novalog and my insurance would only cover the generic. Then they decided they would only cover Novalog not the generic. And now my PartD insurance company does not cover any insulin. So my only resort now is to get my insulin through PartB.
Yes for suppliers also, not correctly processing billing or having a policy that is different than insurance coverage.
MVP denied syringes to use as backup. They denied test strips that work with the Libre 2 reader, though they covered the reader. I dealt with it by giving up and buying my own syringes and test strips.
Yes, I believe the year was 1980. I attempted to have BCBS pay for a new insulin pump. They denied me twice. I submitted it in an article to the local paper & said that it was denied twice. Once it hit the paper it was covered within a few days . BCBS didn’t want to lose any subscribers. The pump was so heavy that I needed heavy men’s pants with a strong belt to hold it up!!! But, look how far we have come!!!
Years ago, my Humalog was no longer covered and I had to switch to Novolog. That was an easy fix. However, I’ve had issues with PBMs’ ordering systems not allowing me to order because they think I’m on Medicare (I am not…. too young), they have preauthorization requirements for items that don’t require PAs . Takes lots of phone calls to my doctor and to the PBM/DME supplier to get it all straightened out.
At first Medicare didn t cover sensors and we just didn’t use because we could not afford but when they started we got the sensors and got better rest knowing we didn’t have to worry about severe lows as much
It’s not the insurer but the pharmacy benefit manager (PBM) contracted with the health plan who caused me endless headaches every year when the “Formulary” changed. Each January the PBM would stop covering either one of the insulins I use and/or the CGM and try to force me to use their preferred brand. I finally got so fed up that I now use the insulin manufacturer coupons to get drastically reduced prices on my preferred insulin by paying cash and not using insurance. I tell the insulin manufacturers that I’m uninsured to qualify and feel no guilt whatsoever about this. So long as PBMs are permitted (by Congress) to get kickbacks (called Rebates) from the pharma companies to include their brands on the formulary, patients will continue to have limited access to what they need and will overpay. PBMs are evil !