Insurance company appeal

I was wondering if anyone has any experience with an insurance company / prescription substitution appeal. Allow me to explain.

In December of last year I received a letter, as I'm sure some of you have, stating that my insurance will no longer be covering Novolog and that I would need to use Humalog instead. I didn't really think anything of it at the time, I just informed my endo that Jan 1 I needed to switch and I started ordering Humalog Jan 1.

Well fast forward 4 months and to make a long story Humalog and I do not make a good pair. My A1C is up, I'm going low all over the place, the whole nine, it's not pretty.

Anyway I talked to my employer who was really cool about it and got back to me today with some information saying that I could try to appeal the substitution by getting my endo to state a case for an appeal.

So my question to the group is, has anyone done this? Has it been successful? Any pointers you could give me?

To be honest I'm almost afraid to ask my endo to do it, as it "feels" like he would be putting his neck on the line and I would hate for him to do that for me. My next appointment is not for another month though so I figure in the meantime try to gather as much information as I can. If any of you have any experience in this area I would love to hear about it.


Doctors and their staff deal with these issues every day. Just make sure you discuss with your endo that the humalpg isn’t working well for you and that novolog does. Ask him to document that in your records and request an insurance appeal-- they will probably have the secretary or nurse make the phone calls. I tried to file the exact same appeal for the same reason and they actually denied it because I had never used humalog so there was nothing I’m my records to indicate that I couldn’t switch… Basically it was me just saying “I don’t want to” in my case. Don’t be bashful asking for your doctors office to help you on this, that’s part of the service you are paying for…

I've never done this so I can't speak to that part of it, but I doubt your endo would feel that way as he probably does letters for patients all the time. And if you have been telling him all along about your problems with Humalog, he has sufficient documentation that it isn't working well. The worst that can happen is they remain rigid and say they won't cover it. Then you have a rough decision, but I was wondering if you are aware there are, in fact, three fast acting insulins. The third is Apidra and it is the quickest acting with the least tail, though of course, there isn't an enormous difference. It seems some people do well on one of the rapids and don't on another. Have you tried Apidra? It's worked fine for me though it's the only one I've used. It would be easiest of course to return to the one that you know works well, but just wanted to let you know there is another alternative.

Hi Uproden. I have this insurance appeal problem annually. First, they would prefer that I use Lantus rather than Levemir. (It has been well documented that Lantus made me sick, so they don't argue about it.)

Second, they want me to use Novolog rather than Apidra, and third, something OTC instead of Celebrex. My PCP sends letters each year pointing out that Apidra is necessary for me to manage my blood sugars; and that Celebrex is the safest pain killer for me at my age with my peculiar stomach.

In fact, this "conversation" is occurring right now... I think you should ask your endo for his help since it's really part of his job. Good luck!

It's not a big problem. All you need is a letter from your Dr. saying that the novalog is medically necessary. They do it all the time. We have bcbs and they had no complaints at all.

Thanks all, I really appreciate all the info, it's been extremely helpful!!

Dr Bernstein during his monthly Q/A talked about this a bit a week or so ago. It's available online.