Insurance double-whammy

Within the last two days I’ve been denied payment for CDE visits by Aetna, and ability to get Fiasp from Express Scripts. I’ve appealed both through Express Scripts and in the case of CDE, via the hospital (change coding so Aetna would pay) and Aetna. No appeal routes are left.

None of last year’s invoices or prescription requests were denied, although my endo needed to submit pre-approval arguments for Fiasp.

I understand the insurance companies and PBM’s business model is not-paying, but this has ramped up in this plan year for me. Diabetics are a very large population of chronically ill patients. I can imagine this is a ripe target for reducing payouts.

I’ll start getting Fiasp from Canada and paying for my CDE out of pocket.

Uggh. From what I’ve heard, Aetna is notorious. How do they justify not allowing a CDE visit? Is there a yearly limit, or just not permitted at all? And for Fiasp, have they just eliminated it from the formulary?

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If Congress is really serious about tackling health care, the first thing they should create is an unbiased panel of judges that patients would take their medication appeals to. Having the entire appeals process in the hands of the very entity that denied the claim in the first place is just complete lunacy.

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Not paying out—denying claims—isn’t a flaw in the business model, it IS the business model.

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They didn’t have a good answer, other than it’s not covered. I looked into it a bit and found a different code the CDE could use when submitting the invoice that would be covered. She was willing to do it but the health system she works for wouldn’t adopt it. They said it was coded properly.

Fiasp is off their formulary (and was last year as well) but supplied it last year based on my endo’s justification. They wouldn’t accept the same justification this year. But this year they did restrict the short-acting insulin to Novolog only. Humalog, which I have used for 20 years, is out.

Get the government involved and I am not quite sure you will see improvement. For decades I was in good control and saw my endo once a year and A1C always about 6.0 where they wanted to see it. Then I went on to Medicare and Medicare insisted I had to go visit endo twice a year to keep Medicare coverage because they told me that will save Medicare money. If you can stay in control with 1 visit a year, I don’t see how 2 expensive visits will save money. Then I went on Dexcom CGM and Dexcom requires doctor notes within every 180 days (I am on MDI, not pump) in order to continue receiving Dexcom subscription under Medicare.

The Government does not make any more sense to me, actually even less, than the insurance companies. There is some serious fixing that needs to happen everywhere at all levels for diabetics.

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And the problem here is the battle that we must wage everyday fighting for what we need. And it goes on forever and the insurance companies know we will get frustrated and give up. I always keep pushing. I mean I am paying for this coverage and my medical team and I have decided what will work best for me. Fortunately my doctor is willing to fight right along with me. But wow, it is so darn frustrating! Hang in there and keep fighting the fight!

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The government is the only thing that can regulate the insurance companies. I’m not pro government for anything, Congress needs to start actually doing something about these situations. Traveling around the country and giving talking points and speeches about legislation that is dead on arrival is not good leadership. They need to start making a dent in the bulletproof insurance business models.

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That is the bottom line I think we can all agree on!!!

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I know at one point my insurance required I switch to novolog instead of humalog, all I had to do was try it for a month and tell my endo it didn’t work as well (it didn’t) and my endo could then write a special request for it to be covered. I also had to try Apidra at one point. I did have to pay more for getting one off of the formulary, but I get a 3 month supply at once and I believe the difference was only $40-60 for that 3 month period. So it was worth it for me.

They bargain with the drug companies to get a better price, so one year it might be novolog and another year it’s humalog. But you can bypass that system usually if your endo is willing to do the work of proving the need. But I have had Blue Cross or Blue Shield before and it always worked with them. Who knows with other insurance companies if it will work.

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Also a consideration. Humalog comes in concentrated doses. Originally when I got my pump the doctor thought it might not have enough insulin in it for 3 days for me, so they switched my prescription to the 200 (double strength) instead of the 100. I didn’t end up needing it but just stayed with it anyway, I believe I had read people think it works better anyway. I’m not sure because I’ve only ever had the 200 in my pump and injections with the 100 when I’ve needed to use it still works fine.

But novolog doesn’t come in a concentrated strength, so that might force coverage, although maybe still at the more expensive amount. Or who knows with insurance companies!!!

I had BCBS for years - and they were fantastic from my perspective. They truly let my endo determine what was right for me and supplied it, albeit with a higher deductible. Aetna has been just the opposite.

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Yea, I’ve been happy with them (BCBS) too for the most part. I’ve appealed a few things over time and it has always worked. A little slow or frustrating in protocol you have to follow sometimes, but that is just the way it is.

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I am having trouble with BCBS due to them making Humalog a formulary exclusion. What they cover I cannot take due to a bad allergic reaction to novolog and novolin. My endo has been fighting to get it approved with no luck even though it is medically necessary. All they will say is that it is a formulary exclusion that 5hey cannot cover at this time after covering it for several years. Hopefully one of my state representatives will be able to help.

Is this an employer based plan? If yes, sometimes employer HR/Benefits reps can help with appeals or exception processing. My employer had direct contacts, and they were able to get override entered in my account notes, so it didn’t come up again at each refill, and was processes correctly.

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MN, I think, is introducing legislation to prohibit mid-year, non-medial Rx switching by the PBMs and insurers. I think we are the test lab to see if this helps.

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They wont cover Humalog? What a racket!

I had fiasp denied too. My endo recommended it due to highs after meal and then lows thereafter. It wasn’t as simple as a ratio change so she recommended fiasp.

It was denied and my endo appealed it with making a case for medical necessity, but it remained denied.

I have UHC/OptumRx through employer. Both were not helpful in dealing with this issue and told me to contact the other one to resolve. In the end, I just stayed on Humalog since could get anywhere with insurance. I looked at the cash cost of fiasp but was too expensive.

Regence/Blue Cross made me switch from Humalog which I had been taking for years to Novolog. For me, the switch was simple.

I’m going to buy it from Canada (mail order) for $70 per vial. Not cheap by any mean, but much less that retail in the US. If I was closer to the border I’m sure I could get it for even less at the pharmacy.

I was mixing it 80/20 with Humalog. Not as affective as full strength, but better than short-acting alone. I believe someone else on this forum (don’t recall who) was mixing it 50/50 with short-acting.

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