Do you have a question about how health insurance works, or are you having an issue with health insurance? If so leave us your story and ask the group how things work. No one can know your specific policy, but generally insurance works the same way most of the time. If you need advice, even if that advice is where to get advice, let us know.
Why is it my insurance pays for my insulin(well i pay a co-pay) but they wont cover my test strips or needles?Doesnt it make sense that im gonna need both of those if I need the Insulin?,Is this the norm?
Great idea for a discussion Rick!!!
I had the exact opposite! Insurance used to pay for only my test strips, but not my insulin. I was told this was because I did not have prescription coverage, but test strips counted as a durable medical supply?
Debbie:
It is not the norm, but your plan may include a specific exclusion for testing supplies. I suggest calling your insurance administrator (employer representative or sales person if a private plan) and make the same argument to them. Almost all plans cover strips in some fashion. Remember that they are not covering strips because they are nice. Covering strips is a way to reduce the long term costs of your disease to the plan. The theory is that the better control you have the less overall cost you will be for the plan.
Now, I also suggest you get your plan document and review it carefully for the testing provisions. Many time the plan document will address test strips specifically. You can obtain the plan document from your employer representative or sales person.
I wish you good fortune with getting the plan amended to pay for the test strips.
Rick
Kristin:
That used to be pretty typical. So many employers had the idea that prescriptions were really the least of he health care cost, that for years many did not cover them. Unfortunately in today’s environment prescriptions may account for over 20% of the total plan cost. For those who do not have coverage such as Debbie or yourself, if you are working and do not have good coverage, you should check to see if your company has a Section 125 program for prescription costs.
Using a 125 plan allows an employee to use prefederal tax dollars to pay for health insurance costs, including prescriptions. It effectively reduces the csot of items such as test strips by 10-15% for most people.
Rick
Thanks Rick,My Quest for today is fighting with the Ins. Company,May the best woman win,MEEEEEEE
you go girl!!!
Even if you do not get the strips approved, it is important to let your plan sponsor know that strips are not covered. Employers offer health insurance only for one reason and that is to help their employees and families stay healthy. No other reason makes sense. By not paying for something as expensive as test strips they are really defeating the basic purpose of offering the insurance.
If they are not covered, my guess is that an insurance sales person sold a non coverage option to the employer. There are several companies out there who do things like that. In fact in an insurance sales meeting once a sales person advised me that excluding diabetics form coverage would significantly lower the company premium and he advised it. Of course he had no idea he was speaking to a 25 year Type 1 diabetic and when I tossed him from my office he said we could accomplish the same low rates by excluding the experimental drugs for heart disease.
I had the feeling had he not been talking to a diabetic he might have sold that plan, after all everyone wants lower premiums, but in getting them the company has to remember why they have the program to begin with. Unfortunately some company managers just do not have enough knowledge about disease to make good choices.
What make me really angry is that insurance companies choose to cover viagra but not test strips claiming that test strips are not medically necessary but VIAGRA is?
Yes, that is a real problem. All we can do is make sure your employer or plan sponsor knows of the hardship this is creating. It is not so much about viagra vs test strips. Rather the approach is that test strips save lives and reduce long term costs and be sure and talk to the plan sponsor. The insurance company only administers the plan, that the plan sponsor has chosen. So many times people complain to the insurance company however they only do what the plan will allow. It is always best to tell the employer or plan sponsor directly so they know hte hardship.
Rick
As a reminder, to all people who are employed. You likely qualify for a section 125 deduction at work. If you do you can lower the post tax cost of medical supplies, drugs and services by placing money in a seciton 125 account. Section 125’s are deducted as a pre federal income tax deduction. You may then withdraw that moeny without paying federal income tax on it provided it is used to reimburse qualified health care expenses. If your company as a section 125 plan and you have not signed up for the plan you should check into it.
Rick Phillips
I believe that not covering testing supplies may be illegal under federal law. It seems to me that it was a part of the HIPPA regulations. Many plans do things such as this until they are actually challenged in court. Until they are challenged in court like that, they will often grant an individual coverage, but not everyone in the plan. Each individual has to challenge it. It sucks that insurance companies do this, but there are so many different plans out there that it is almost impossible to police and most people won’t challenge, just accepting what they are told
The law requires that plans offer coverage for testing supplies if they offer that same type of coverage for other items. Typically one might look at supplies for ostomy issues. Usually if the plan excludes testing supplies it has been legal checked for this type of discrimination and an attorney feels it has passed the test. One factor many plans have is an internal appeal mechanism before pursuing a legal remedy one should always pursue a plan exception for the materials needed. Again the argument has to be that overall it will be less expensive for the plan to test than not test. It is an easy argument to make. Simply put one heart attack or stroke prevented will more than compensate for all the test strip usage for a couple of years.
Hey Rick,
This is what I found out,My insurance is through my husbands and it is a group Ins. .The same on I had for myself when I worked at the hospital. Anyway the medicine part of the plan is covered by Maxor. So, if I buy my meds or supplies at my regular Pharmacy only a few things are coveredby my co-pay and still at a higher co-pay.So my insulin is covered but not my strips or anything else. Now if I do Maxor by mail or drive 50 miles to the Maxor Pharmacy,I can get all my supplies covered for my copay or at a much much lesser price with a 3 month script. Strips, needles, etc. Now why is that so? Is Maxor getting a big payout from the Ins. company…and why didnt they explain that when ya did your signing up for the ins.?
Thanks,
Deb
Great discussion Rick.
For the last 17 years we had fabulous coverage at work with a local HMO. I didn’t realize how good it was until we switched in '09 to BCBS, with scripts being handled by Express Scripts. I started calling them last November to ensure a smooth transition. NOT. I have been on the phone nearly every day with them. My test strip order just sat there for two weeks because it was “for too many”. In checking it online the status said “in progress”. A phone rep would not take any action because it said “in progress”. Finally I spoke with a supervisor who said the doc needed to call and approve the amount for 8 down to 6 And now I’m having problems with my blood pressure meds.
A fellow employee was sent 3X the amount of her migraine medication and they want her to pay for it all at once, even thought it was their mistake.
I am getting really angry just typing this.
But, that is a great idea to report these problems to your employer. The company I work for is worldwide and has a big HR department. On Tue morning I’m gonna call them and see who this should be reported to. At least I’ll feel better.
Kathy:
Express scripts seems to have these problems. What is solicit all new scripts each time a mail order company changes. One thing I do know about express scripts is that they tend to mess up summer insulin orders. I suggest either doing the option of the local pharmacy or find am absolute address where someone will be there. I started having mine delivered at work and I instructed them to only send it out on Monday or Tuesday. Each time I found an order shipped out on Thursday or Friday I declared it spoiled and demanded a new batch. After about the third one they complied with my request. Lets face every time someone claims an order is spoiled they lose mega bucks. There is nothing they hate worse than that.
As far as complaining to your company be sure and do it loudly. I will grantee the minute the Personnel department gets that complain they will call the insurance company. When they so the employer will not be happy. The account hinges on employees being taken care of.
Rick
Deb:
The mark up on test strips is over the top. In an effort to cut costs. (likely about a 15% markdown) insurance companies require mail order purchases. Local pharmacies get as much as 50% mark up on strips. One thing to thing you can do about it is to go to your local pharmacy and ask them to join the Maxor network. They will not do so, but they ought to know why they lost a loyal customer. My bet is that your local Pharmacy has rejected overtures from Mxor base don low reimbursement rates. But if a number of folks in your town are in maxor, they may want to reconsider and nothing beats a customer pointing it out to them. Finally also go to your employer and ask that the local pharmacy be included in the maxor network or be given special permission to charge higher rates since they are local. I know when i was administering insurance I included two local pharmacies as mail order (90 day scripts , higher reimbursements) because I did not have a stomach to run the local guy out of business.
Go ahead and get a script and ask for a 90 day script for needles, strips and lancets. As the doctor to specify the meter you use and suggest to them you use at least 6 per day. I use 8 (unfortunately i really do use 8) but the average is 6. get it sent in and you will be a happy camper. Many of use mail order for strips, lancets and needles so it will work out well. DO the number of shots per day plus at least one or two. Shortly you will find that you are overrun with all these supplies .
Well as opposed to being upset with a pharmacist or a pharmacy the issue rests on the mail order vs retail charges to the employer. Of course i have not knowledge of what a local pharmacy does or does not charge. What I do see on a regular basis what a plan is charged for mail order vs retail purchases. Remember mail order firms work in very large quantities at the manufacturer level. When I said local pharmacies mark some up 50% what I really mean is that the typical charge for a retail pharmacy is about 50% over that same charge for a mail order pharmacy (my apologies no need for the blood to boil).
the question at hand was why plans discount mail order so much over retail or require a mail order for certain products and not others. Typically the deepest discounts for a plan on its routine non drug ingested products, such as test strips and lancets.
Now as for the local pharmacy, when the local company I wrote about has over 70% of the walk in business form a single employer and if that employer incentivizes mail order well over the local pharmacy then the local company could have easily gone under. It was important to change the incentives to keep them in business I was glad to do it.
Now as pitch for a local pharmacies. The local pharmacy offers far better service and if a plan can continue to do business with the local retailer, the employees will be well served. Unfortunately, the large mail order firms know this and where they can they will do everything to run them out of business. Its a sad situation. If you can get your scripts locally I strong suggest you do so. If the employer or plan sponsor has mad e a choice for mail order service, it is being done on what is believed to be a lower cost.
The money is not at the local pharmacy. in act if the large mail order companies did run the locals out of business, drug prices would go ballistic even more than they have. Big pharma and yes the mail order houses are making the money, dont blame the locals.
I guess I missed my editing deadline sorry for the typing mistakes. Yuckers
Rick
okay then,why is it when I was on Byetta…my local pharmacy was charging me $249.00 a month after talking with the ins. company and Maxor pharmacy they informed me that I could have gotton my Byetta,drum roll please,for $50.00 for a 3 month supply!! so,for 5 years I paid $249.00 a month,when I could have been getting it for $200.00 dollars a year!!!..now thats a mark up!
I suppose now as I reread my response, I want to clarify where I stand in the health care system. I am an employer representative. I choose plans and plan options for employee groups.
Now to restate the 50% comment. What i always see is what a mail order company charges for products vs what a local pharmacy charges. For test strips it is usually about 50%. Now make no mistake the local pharmacy could never compete on that basis. Big mail order may choose to make things like test strips a loss leader ( i hate it when they do stuff like this) or thier costs may be that much less. regardless the employeer or plan sponsor can often see a 50% differential, thus the reason they incentivize mail order.
Interestingly enough as time as has gone on the two price points are moving closer together. This is likely due in large part to deep discounts by local retailers and price increases by mail order pharmacies. In fact for many drugs (low volume high cost) the local pharmacy cost and the mail order cost may be roughly equal when shipping is figured in.
That however does not apply generally to non ingested items, or at least they have not in my area. Again the original question is why do plans require use of mail order pharmacies. The short answer is that the administrators believes mail order is cheaper for the plan. Specifically why would they require mail order for test strips and lancets and needles? Well at some point the administrator felt strongly that the plan could save money by forcing this requirement. Overtime the plan administrator will figure out if it has made a good or bad bet. Generally these are short term arrangements, the mail order company raises prices, and the local pharmacies tend to lower prices or go out of business (which is not healthy for consumers).
I seem to have offended as a result of an errant 50% comment. I stand by the 50%, however, I hope I have clarified its context.