Insurance Coverage


#1

I have type 1 diabetes. I have had it for 35 years now, no cure and I use an insulin pump called OmniPod to stay alive, it lets me have the best blood sugar control so far. I change the pod every three days and the PDM lets me check my blood through the system.
Ok, here is my problem…
My insurance, United Healthcare, which is my only option through my husbands company, is required by law to cover blood testing strips. Yay! I check about 10 times a day so bring on the strips! But then I ordered them and the co-pay was
300.00!!
I spent hours trying to sort out the problem. United Healthcare has a tiered program and my testing strips are on the bottom tier, meaning the most expensive co-pay. My doctor and I wrote two appeal letters, saying the Freestyle strips I needed were medically necessary but United Healthcare denied me a lower cost.
They will charge me a 60.00 co- pay for strips on the high tier which do not work with my system. They are for a less accurate meter, and would cause my readings to be off 20-30 points. I would have to cary around MORE diabetes supplies and manually enter my numbers into my Omnipod.
How is this ok?! These are the times I feel that no one gives a xxxx, I can’t afford this disease and why should I go on?
I have one vial of 100 strips left from my old insurance which would cost me around 50.00 for 1,200 strips. I don’t know what else to do at this point… I guess take WORSE care of managing my diabetes? Thanks United Healthcare, you suck!

If anyone has an idea for my please let me know, running out of strips soon.


#2

Appealing an insurer’s decision can be overwhelming and confusing. but you need to do this immediately and ask for your record to reflect your need for a product not in the formulary. You need to write an appeal letter and ask your insurance company to reconsider their denial of coverage.

You must prove the medical provider thinks the recommended treatment is medically necessary. Ask your doctor - and perhaps other medical experts - to provide written documentation explaining why.

Good luck. My strips are not in the coverage formulary but they talk to my pump so my doc makes sure to write the RX to indicate this need.


#3

Unfortunately my experience with UHC has been the same / worse. For my strips (which are chosen since the meter communicates with my pump but are the lowest tier in the UHC list), my co-pay is $80 for 90-day supply. (And $31-something for 90-days’ supply of lancets. That’s even more ridiculous, given how inexpensive those are.) Even with the medical necessity letter (which just allows me to purchase the brand I want), we just swallow and pay. Thankfully we can afford it.

If I were you, I would think whether you could do more strategically timed but slightly less frequent testing as a cost-saving measure. I do about 7-8 checks per 24 hours (when all is well of course) and have found that to be sufficient for great control.

At the same time, I would also try to find out from UHC what is their preferred way of ordering the strips. In my case, it turned out that if I bought them at the local pharmacy, the co-pay would be even higher. But by placing 90-day orders via their mail-order pharmacy, I am only charged the amounts listed above.

But it is a pain to deal with these for-profit insurance companies and you are right – they don’t give a XXX for us as patients. We are customers from whom they want to get the highest profit. Pure and simple.


#4

Thanks for your response. I have always ordered from a mail pharmacy for 90 day supplies. The 300.00 is my co-pay. My doc wrote a letter explaining that the strips I need only work with Omnipod, they still denied. The real problem is not that they don’ cover the strips, the problem is my unaffordable co-pay of 300.00. If I had no insurance the strips would cost me close to 2,000.00. While they do cover a large amount of the total cost, it doesnt help if I can’t afford the 300.00 co-pay.


#5

When I trialed the OmniPod several years ago, I decided to use my favored test strips that were not part of the O-Pod system. I didn’t find that practice difficult to live with. I know there’s a little more button pushing required but I didn’t mind. Maybe it’s possible for you to use another, more insurance-favored strip, going forward.

I have a big problem with these tyrannical insurance company edicts but some battles are not worth fighting.


#6

I am not a fan of UHC. This past January they dropped my fast acting insuiln from their formulary so I now must buy it at straight retail. It will be a few months yet until I can look into switching to another plan. Grrrrr.


#7

I faced this exact same situation several years ago. I ordered the strips that were covered, sold them on eBay and bought the Freestyle strips on eBay that worked with my Omnipod PDM with the proceeds for essentially the same price. I did this while my appeal was running through the system. I did this quite successfully for several months until I got the actual strips I needed covered.


#8

Thanks for responding Terry, its not so much the extra pushing of buttons, but carrying another blood tester, which I already have from before the omnipod. I used this meter and strips before omnipod. When I used it again it was 50 points off from my Omnipod, yikes! I already feel like diabetes has made me ADD because it is all I am ever thinking about before everything else.


#9

I hear you on the gadget load. I carry a day-pack as my “man-purse”! I’m in the process of switching back to a DexCom G4 system since I don’t need the extra display on my iPhone and the G4 transmitter has better range, less data dropout, and lives longer than the G5.

Unfortunately, I think our load of D-tech array is going to get larger rather than smaller with the emergence of the closed-loop CGM/pump systems. I will tolerate it, however, as long as the gadgets produce more value than they cost in terms of my attention and energy.


#10

Now that’s the first morally defensible foray into the test-strip gray-market that I’ve heard!


#11

You should appeal. You very likely might lose the first appeal, but appeal again. Insurance companies expect most people to not appeal, but if you are persistent enough, you may have success.

I do not use the Omnipod, but I do use the Freestyle Lite. I consider it to be the most accurate and consistent meter that I have ever used.


#12

You should always ask the pharmacy how much it would cost out of pocket. I found the co-pay on the lancets was $90 for a three month supply but if I bought them without using the insurance (from the same pharmacy) it was $30. Always ask the cash price…


#13

Sorry, got to totally disagree with this. YOU may get “great control” but if the OP feels she needs 10 + tests per day, that’s how many she should use. Personally, if I were not using a CGM, I would say that 8 is the absolute minimum number for an exceptionally good day (and how often to problem-free days come along). That would be 3 before meals, 1 before bed, 2 before driving to and from work, plus 3 more for 2-3 hours after meals.

Of course if you live an absolutely regimented life and eat the same thing every meal you could probably get away with fewer but most of us don’t want to live that way.


#14

I have asked, the cost was 1,750. That is why I always use a mail away pharmacy.


#15

There is a reason I have lived 35 years out of my 45 with type1 with no complications-frequent blood testing and a very clean diet. I exercise every day and have been in the fitness industry as a Personal Trainer for 25 years. I was a swimmer in high school. All of that exercise means more testing to avoid lows.


#16

I totally agree with you (particularly re: exercise and hypos). I was questioning the poster that suggested you could get away with 7 or 8. That’s why I now self fund CGM. Before that I was testing ~12 times per day.


#17

Getting a prior authorization for strips that are paired with a pump is a fairly easy argument. Ask your provider to help or make the case yourself.

Also ask Insulet to make the case for you. They made the deal for strips and should help you get them. I pushed Medtronic to do this for Bayer strips.


#18

@Mark_Harmel – The original poster’s problem was not denial of any strip coverage for her pump-associated meter. It is rather having the insurance company place her preferred strip at a unaffordable insurance tier in the formulary. I’m not certain one can appeal the formulary tier assignment.

I don’t use the OmniPod system so this is not an issue for me.


#19

Terry4 You are right, there is a difference between denial and preferred pricing. Prior authorization can still get the the paired strips covered at the lower preferred price. I’ve done this for a number of patients by calling their insurance companies. It is an issues for many who have paired meter/pump systems.


#20

Has anyone had a good experience using savings cards? All the strip and drug companies promote them. Is it actually a deal for you? Here is the one from Freestyle: https://www.myfreestyle.com/offers