Insurance company denied Afrezza

Finally found a doctor in New York to prescribe Afrezza for 18 year old daughter. She loves it. Her blood sugar was 312 after eating out in a restaurant. 4 unit dose of Afrezza brought her to 180 in half an hour 130 in an hour. Problem is OXFORD LIBERTY is denying her on the grounds that she would need to have significant visual impairment or other severe complication to be approved. They do not care if Afrezza can prevent complications. Has anyone successfully appealed denial of Afrezza and, if so, on what grounds. She has had about four instances of 20s and 30s on her meter in the past month while away at college, despite the fact we were running her blood sugar high. We want and need an insulin that is out of her system in an hour or an hour and a half. Judging by her results from the sample packets this insulin is fast, effective and A LOT SAFER.

I use afrezza and swear by it… I had to have my latest insurance plan preauthorize it, but thankfully that was easy in my particular case.

I’d try having your doctor write a letter of medical necessity stating that she is having dangerous hypos with conventional rapid acting insulins and not with afrezza… I would hope that would work, but who knows. Please keep us posted on this. I certainly hope you can get it figured out, please don’t give up. It has changed my life— I can no longer imagine a life without it.

Also I have recently researched the afrezza discount card, which basically will knock about $150 off the price of a month supply if you have to pay cash… which by my calculations would have brought the cost down to about $5 / day to pay cash for it… that’d be money well spent for me. I broke down those calculations in the recent post labeled something or other about Afrezzahub

1 Like

We have mentioned the hypos and can prove them on the download of the meter. We will pay out of pocket, and I know they have a $150 knocked off the script but is that a one time thing only? I also know their discount is in effect only until next year. We are not new at this and have been at this for ten years. We have successfully appealed for Apidra, had continual appeals for sufficient testing strips, appealed for Dexcom successfully twice (now she won’t wear it). We have one more appeal after this one. Problem is the endo who prescribed the scripts seems to have a very busy practice. We have switched endos before who have refused to fight for adequate strips. I hope the endo will follow through with us to the end of the appeal process. Her receptionist told us we can’t appeal as the insurance is demanding visual impairment as one of their grounds. Naturally the endo cannot lie. Hoping for the best, and it won’t end here. We will appeal at a governmental or State Insurance Board, whatever we can think of we will do. Once Sanofi stops the discount this could get very expensive. She seems to be using quite a bit of Afrezza… the dosing is not equivalent. But, no, not going back to Novolog, Humalog or Apidra. Been there. Done that. There is no comparison

1 Like

sorry about the typo. It is Apidra that she was using. I have Afrezza on the brain, LOL

My understanding is that the discount card will last until the end of 2016, can be used every month until then… then it may or may not be replaced, revised, etc… I hope that by then more insurers will be covering it without a fight… I’m imagining that’s part of the intent behind the discount is to get more customers built up as they negotiate with insurers…

Good luck, keep up the fight. Keep pestering the endo until he does whatever it takes to back up your appeal. I’d stop at nothing to keep my afrezza.

1 Like

We will certainly fight. But it is good to know that the discount will be covered for a full year. Irony is Afrezza is covered. I have never heard such a ridiculous excuse for denial. You need to be visually impaired to get a script? Oh come now… Usually the appeal process in the past has taken a bit of time, two go-arounds. This is the first go-around. I can afford it if we get the discount. And, ultimately, will pay for it even if it puts a crimp on our budget at full price.

1 Like

I went through some pretty gripping anxiety when I wasn’t sure my new insurance was going to cover it… I saw that they required prior authorization… searching on the internet I found people telling the exact same story you’re telling now about the visual impairment, etc… I’m glad it turned out the way it did for me but I had made the same decision, that ultimately I would pay for it no matter how much it cost or what sacrifices I’d have to make to do it.

I have a member owned group plan… they use the caremark network for meds, but (I just learned this the other day) I can take any issues directly to the group plan administrator instead of caremark and they have overriding authority for any caremark exclusions, etc… so thankfully it turned out ok for me

1 Like

There is a second appeal. We know from past experience that they often will deny the claim and even the first appeal Then you go back with documentation and we did get her Dexcom on the second appeal. We also got her Apidra approved I think on the first appeal. We have had to fight for adequate testing strips countless times. For the next year we are okay because, although expensive, we can cut back elsewhere. She just picked up her first month’s script (and she may need more, I’m not sure yet). Sanofi takes $150 off each box I think. She got two boxes of the 8 unit cartridge and one box of the four unit cartridge for $350. I think it may be even less expensive at Costco or Sams; we used Rite Aid. After next year if they don’t renew the discount, it would cost upwards of $700. I think she will need another box of the 4 units per month at least. Diabetics and their parents friends, in fact most people with health issues should start a movement, much like Act Up, to get their medical needs covered. We know the drill. I think we will win in the end on the second appeal. Or time to go job hunting for better insurance coverage. That’s one way.

1 Like

Check out truetest strips on Amazon if you’re looking for a good low cost cash option. Glad she got her afrezza and good luck with your appeal. Keep us posted.

Not sure about Sam’s Club, but I know Costco does not accept manufacturer’s coupons, so if you go there will NOT get the $150 off which you mentioned. For myself, I go to CVS for test strips and Afrezza because of the manufacturer discounts. I get my insulin at Costco because I have no co-pay there as opposed to $30 co-pay at other pharmacy’s.