Donut Hole

Two years ago BCBS stopped covering my insulin in December. Last year it was in late October. Today I was told by my pharmacy that this was my last prescription for the year that would be partially covered by insurance. I called my insurer and asked if there was another plan where I could pay more and get more coverage per year. They suggested a plan with no prescription coverage for some reason. Not helpful at all, maybe crack it up to a less that knowledgable rep. I don't qualify for prescription assistance through the manufacturers because I have an insurance plan. I cannot afford +/- $500/month for the Novolog and Lantus I need. I can't be the only one. I'm desperate and hoping someone here can point me towards a solution. Any advice greatly appreciated. Thanks.

I thought that the ACA got rid of caps for medical care and services. It is a shame that something that keeps us alive - literally - is priced out of our reach so often. Insulin isn't Viagra, or Cialis, or even contraceptive drugs.

Hi, David

Never heard of such a thing. I did have a recent problem with Express Scripts filling an order prescribed by my endo for Novolog. They wouldn't fill it! Wanted to send me something different! Despite my doc prescribing in writing for Novolog! Wondering why the law doesn't require a pharmacy to fill a script as written! They seem to think they can make decisions now about our health care without consulting with anyone. Same with CVS filling orders for Bayer Contour Next test strips to use in the link meters to work with the Minimed 530G. Ridiculous! And as I pay for such prescription service as provided by my company, I see them as a monopoly for I, like you, can't afford to go and pay for a separate medication company.

What does your doc say about getting your script filled? Why are your scripts running short? Is there a cap (limit) on the amount your insurance covers? Can you raise that cap?

Our health care in this country is pitiful actually! Think, Europe and Canada are getting more advanced medical devices two to three years before us! Ridiculous!!!!!


Go to and find a new insurance plan! I have the primo top of the line insurance through Blue Cross, Blue Shield. I pay $346 a month. It covered me getting a tandem insulin pump, a dexcom receiver and the sensors as well as all my insulin. For durable medical equipment I only pay 10% of the cost (meaning I pay about $25 a month for dexcom sensors and $30 every 3 months for pump supplies). For Lantus, humalog I pay about $15 per order (which is usually a box of five pens or two vials at a time).

Considering how much an insulin pump actually is out of pocket, my insurance for the year paid for itself the moment they paid for that pump. They have not ever messed around with me about anything and usually cover any Rx I might need a bit earlier than usual. If anything, now that they paid for the very expensive pump, I can just cancel at the end of the year, stop using my dexcom to cut out of pocket costs, and go back to getting $2 vials of humalog at the City hospital nearby (which offers discount programs if you make below a certain income - which they never actually verify).

We also have BCBS coverage and are experiencing the same issue. Novolog (in our case) has gone up considerably each year meaning we meet the cap for prescriptions sooner each year. There is a discount card you can get that will help purports to helpe (if you are 18, my daughter isn't so doesn't qualify). You might ask your endo for samples. That may at least get you a month or two farther toward the end of the year.


You mentioned the donut hole. Are you on Medicare? If so, you may be able to get insulin directly through Medicare without having to go through your supplemental insurance. So if you ARE on Medicare, look into that by calling the 800 number for Medicare and asking. You'd probably need to get a new prescription from your doctor, but I believe you'd have zero co-pay. Prescriptions other than insulin and test strips would not be available that way.

For those of you who mentioned the ACA, it doesn't apply to those of us on Medicare...we're already covered in other ways.


DFresh, where abouts do you live? I was che4cking BCBS in Oregon and couldn't get any details on DME and Rx's.

Thanks for the reply. There is a cap on the amount of name brand prescription coverage. It has remained the same but the cost of insulin as been raised so dramatically that it is no longer covered and my meds- with no generic alternative- are now all out-of-pocket.

Thanks for the reply. My BCBS is almost the same dollar amount per month. I wonder if there are regional differences...odd.

No, not on medicare. I think I might have borrowed the term 'donut hole'. But its virtually the same issue. Only so much name brand medications are covered under my plan- which I have had no complaints about up til 2 years ago when the coverage started going down.

Thanks for the tip. The kicker is that I don't qualify for discount medication on account of the fact that I have insurance. Catch 22.

I know there are regional differences for some things. As an example, I have Kaiser for the Pacific NW and they don't cover CGM's but Kaiser in California does.

I know that I am fortunate in that I notice no difference between Novolog and Humalog Can you try changing insulins? It is really ■■■■-worthy ( that is gets me pissed off) that something that keeps us alive is so expensive that it is out of reach.

Except there are no generic equivalents for insulin so there should be some sort of an exclusion possible. I would read through the fine print on your policy and make sure that those limits also apply to insulin. It might be excluded. You could probably fight this in an appeal.

AS a followup, I suggested seeing if you can switch insulins was based on the fact that insurers "bid out" the products they covers - just like they do with pumps. And it can change year to year, I've been switched between Novolog and Humalog so many times I've lost count. Whichever company gives the insurance plan a good price gets deal and their product is covered,

I'm sure I'll make enemies saying this, but this is a direct consequence of the ACA.

All plans are required to cover a wide range of services that were not required in the past. So, a diabetic, who could buy insurance that covered their diabetes needs but did not cover pediatric dental care, substance abuse treatment and counseling, chiropractic care, and on and on for dozens of things most diabetics have no need of or aren't interested in covering, can no longer get a plan like that.

Because of this, insurers have had to find other ways to reduce costs and make plans affordable. One of the key "loopholes" in the ACA is brand vs. generic drug coverage -- insurers can place annual caps on branded drugs.

They could always do this, but rarely ever did, for the very issues that arise for some patients like we are seeing here.

Hard as it is to accept, money that you were paying in your premiums before to cover insulin now goes to paying for in-patient drug abuse treatment for people. This is not an exaggeration, or a political swipe. It's simply a statement of fact.

If you want coverage that will not have a brand-name cap on prescription meds, you have to buy an exchange "Platinum" plan for equivalent, for the most part. And these plans are very, very expensive.

We're between a rock and a hard spot. Before the ACA I couldn't get any coverage. I tried bargaining saying that I would cover out of pocket the diabetes costs, and since I hade long ago decided that kidney transplantion was not an option - the didn't have to assume they would be paying for that. They still said no. All I wanted was coverage for something else - just cuz I have type 1 didn't mean I was immune to other illnesses and/or accidents. And it's funny, my husband is a metastasized melanoma survivor, he got coverage and just had to wait a year before the possibility of cancer again would be covered.

That could be a partial consequence. However, it is the manufacturers that have raised the price of the product so substantially. My Lantus went up 15% last year alone- I won't throw numbers out I can't verify but they did nearly the same the two previous years. The patents run out in 2015 for insulin so Ely Lily filed an injunction to stop a generic manufacture of insulin, while simultaneously jacking the prices way up. I am way more concerned with the precedent being set by the pharmaceutical company than with the insurance company. The manufacturers are banking on enough type 2s converting to insulin therapy in droves before there is a more broad awareness of the price gouging. After all, could you tell me without looking what you pay for insulin? Not your copay, the cash value.

But I am also showing my ignorance. What is the ACA?

Thanks for the suggestion. I didn't even consider an appeal. The only people I can get on the phone tell me explicitly that they aren't authorized to tell me anything. Frustrating.