This year I discovered that my new insurer did not cover my existing insulin, Fiasp. Instead Lyumjev was covered. So I just changed to Lyumjev. Next year my insurer no longer covers Lyumjev and now covers Fiasp.
This is because each insurer has a “formulary” for drugs; a list of drugs the insurer wants you to use in preference to other drugs which are more expensive for them. We can request the old drug or, indeed, any drug.
I discussed it with my endo a few days ago particularly with regard to changing back to Fiasp; it turns out I quite like Lyumjev. His response, summarised, was along the lines of, “It’s a lot of paperwork and it doesn’t always work.” I.e. it might work but the insurance company can always just say no.
This article explains what goes on better than I ever could:
Once, in the olden days when Victoza was considered hot stuff, my endo thought I should be using it. He needed the approval of some committee of the HMO to prescribe it, and they refused . He said that they thought that my blood test results were too good. I jokingly suggested that I live only on extremely sweet Middle Eastern cakes for a few days, and then redo the tests . He gave me a strange look and said : “Do it.” They approved the Victoza, and have since approved Ozempic and then Mounjaro without blinking an eyelash.
The medicare and ACA plan regulations are aligned on formulary exceptions which is nice. The ACA regulations for formulary exceptions appear to be part of the minimum standards for all health plans but I could be mistaken.
Every plan has to have an exception process. An exception can be requested by an enrollee or their doctor. Step 2 is for the doctor to provide a supporting statement. After receiving the statement the plan has 72 hours to make a decision for non-expedited requests. In the event of a denial the decision can be appealed. States can define their own timelines and exceptions process but the state processes must contain at least these steps.
An exception request is a coverage determination. The plan must treat the excepted drugs towards the plan’s annual limitation on cost-sharing. Exceptions last for amount of the prescription or until the end of the plan year.
From here the regulations appear to differ. Medicare defines “drugs” to include devices. It has has an exception if there’s no biologically similar drug the plan doesn’t have make an exception. So I think in the case of pumps a plan that doesn’t cover omnipod also doesn’t have to cover twiist. Finding out if this is in the ACA is on my list.
A solid plan for getting a GLP-1 exception approved is to have a cardiologist or nephrologist prescribe it and not say anything about diabetes or weight in their statement. The TCOYD docs often scoff at how ridiculous hypoglycemia requirements are because, ya know, give us 20 minutes…
You sneaky devils. Anything to make the paperwork go thru.