Insurance rant

So I just got home from the pharmacy. Ordered a refill of Humalog on Saturday. Was supposed to be ready yesterday. Hadn’t heard from the pharmacy so thought I better check. Turns out the insurance didn’t want to fill until the pharmacist made sure I was using a pump. I’ve been on a pump for 17 years, all with the same company. Been with UHC for over 25 years, first with regular insurance, now with a Medicare advantage plan. Asked the pharmacist if he thought they wanted to change my insulin? The insulin which has worked for me for 17 years. He said they probably did. What do we need doctors for? Let insurance make all the decisions. :rage:


@KCsHubby_Dave, I feel ya!

I kinda believe that every doctor appointment should have a UHC doc/rep/contract specialist on conference call …

I get at least one call/year from the mail order pharmacist who asks, “Are you still taking insulin?”

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if you have Medicare part A and B, Medicare will pay 100% for whichever insulin you wish to use in a pump after a $250.00 annual payment. The Pharmacy is required to send in the pump serial number, model and make. They usually look at it to make this determination. I am guessing that is the reason for the examination.

Not on Medicare, but have UHC - they do so many things to delay or avoid filling prescriptions! I dread August every year – that’s when all my ‘prior authorizations’ come up for renewal. shudder
On the ‘plus side’ - I got notice that I’m getting an insulin delivery tomorrow - three more months of Apidra approved…

Reading these things angers me to no end. Diabetes is serious and complication devastating and prohibitively expensive for both the patient and the insurance companies. Then they put ridiculous policies in effect that impact long standing diabetics as though something “magical” might occur once a year, and the pancreas will churn out sufficient insulin. Prescriptions should be filled in a timely manner and this should be mandated, any delaying tactics should be met with fines and penalties, period. Medicare and private insurance seem hell-bent on causing complications or loss of control. I am particularly disgusted that more preventative services such as regular foot care are not covered when needed, versus every 61 days. How the heck does a paper pusher know when a diabetic or someone suffering from peripheral vascular disease needs foot care and a quick assessment of neuro and vascular status of lower extremities? I seriously doubt the medical directors of Medicare or any insurance company have ever actually seen a patient much less treated one. I dealt with this nonsense for twenty years, trying to assist patients, drove me NUTS. Ok, now I will step down from my soap box.

Happy Birthday Thas!!!:birthday:

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When I switched my insulin to mail order through UHC, who for my area now uses Optum for rx coverage, it was absurd. Hey needed a new rx, my endo sent it in as “use 2 vials per month via insulin pump”. My endo and I each got a call saying there was a problem. I called back, the operator says the rx was wrong, it needed to say how many units I inject per day. I said I’m on a PUMP. She had me talk to the staff pharmacist in hopes I could give him the info he needed. He gave me the same spiel. I said again, I’m on a PUMP. He said oh ok, do you know about how much your pump gives you per day? Now we all know it depends on the carb load and any other randomness. So I said I fill it every three days; I can tell you I usually do 120 units on a three day fill. He accepted that and put the rx through.

When it arrived, the label said “use 2 vials per month via insulin pump”.

These companies are playing God with chronic patients because we hurt the thickness of the lining of their pocketbooks, and it royally )!$$es me off.



It’s like trying to pound square pegs into round holes! The pharmacists work with systems that demand quantification to ensure you don’t receive “more”. OTOH, our docs write prescriptions every single day, so they should know how to write a prescription that the pharmacist can fill. By law, your label has to say what the doctor wrote.

I would recommend you to ask your endo to write a prescription that says, “Use ‘X’ units/day for delivery via insulin pump”. ‘X’ should be enough to get you enough insulin so that if you have a bad cartridge, you won’t end up short.

I was asked yesterday if my son still needs Apidra!



My endo does exactly that and has had to quantify my daily insulin dose for many years. I tell her how many vials I need for 90 days and then we do the math to turn that into a daily dose for my pump. For example I want to receive one vial of insulin per month or three vials for 90 days. So that is 1000 units times 3 divided by 90 or 34 units per day. She then writes the prescription showing 34 units per day for use in an insulin pump.



To counter my own point above, about 10 years ago, I learned the hard way that endo-speak (as written on a prescription) and pharmo-speak are frequently at odds, so these days I do tell my endo HOW to write the script in a way that the pharmacy tech will understand it.

That still doesn’t make jumping through unnecessary hoops any less frustrating though! :rage:

Bingo. Exactly the same here.

My prescription is written for 40 units a day. Just as it has been and as it was three months ago when it was filled. The problem was not the prescription or the pharmacy. The problem is the insurance, in this case UHC. They won’t let me get a more accurate meter because they don’t cover the strips. They stopped covering my CGM after they covered it for two and a half years while I was on Medicare. They want to change my insulin. I could go on and on about health insurance. But couldn’t we all.

I have gotten mixed messages on whether Advantage plans are allowed to force you to use their formulary insulin. If you are getting reimbursed under Medicare Part B, my understanding is that you are not bound by formulary restrictions. However, if you are getting insulin as part of your Advantage plan prescription benefit, you may be bound by formulary. This is one reason (of many) why I went with traditional Medicare with a Supplemental policy.

As you’re finding, Medicare UHC is a completely different beast than private UHC plans. However in every situation UHC is restricting choice…

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In my endo’s defence, this is the first time in 12 years of pumping that any pharmacy I have ever used has asked for a daily dosage. Every single pharmacy before this has allowed either “use as directed via insulin pump” or “use x vials per month via insulin pump”. I did call her office after this episode and the refill nurse marked my electronic file with how they need to write it next time.

Between that and the test strip thing that happened with my first refill of them this year, I feel very persecuted by the health insurance industry. Their only saving grace for me is that they do 3 month fills by mail order so with all the stuff I’m on I save ~$80 per month in copays.

The correct answer to which, of course, is “No, I’m dead.”


Just to make matters more complicated (not to excuse UHC or any other insurer), that company also administers a lot of employers’ self-insured plans. This is our situation, but thankfully my overall experience is much better as a result. My husband’s employer has very reasonable coverage for everything we’ve needed so far, but it uses UHC for the administration of all claims, etc. So neither policies nor prices for the end consumer are uniform across all UHC customers. Which actually points to what I think is the root of a lot of health care costs in the US – complexity and opacity.

To the OP – I am sorry for your experience (that so many of us have had in some form too). Patience and persistence!

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I’m paying $800+ for three months of novalog, on medicare and in the donut hole after the first payment. I was paying $500 a month before I got in the hole. How do you just pay $250 for the year?

Fritz I use a pump. On Medicare insulin on a pump is part of the DME not subject to prescription coverage.

I have CVS for pharmacy benefits.

There are two levels of ‘co-pay’ for pharmacy benefits on my plan

  • 30 day supply
  • 90 day supply.

There are three tiers of drugs

  1. generic
  2. preferred brand name
  3. non-preferred brand name

30 day cost

  1. $10
  2. 20% of cost or ( $25 min / $50 max)
  3. 20% of cost or ( $50 min / $100 max)

90 day cost

  1. $25
  2. 20% of cost or ( $62.50 min / $125 max)
  3. 20% or cost or ( $125 min / $250 max)

Insulin is covered at ‘tier 2 - preferred name brand’. Well, only the insulin listed on the CVS formulary. <cue evil movie music soundtrack>

CVS is also playing doctor with my life as Humalog was removed from their formulary in 2016, and Lantus was removed in 2017. I have switched from 10+ good, stable years of Humalog and Lantus (after switching from the ancient beef/pork R and NPH) because of CVS - not because Novalog is better. I am actually still using Lantus - the savings card from Sanofi is actually quite good - I paid $10 for three vials of Lantus at my last refill even though CVS doesn’t cover it at all. $10! I have never paid $3.33 a vial for insulin, even going back to the 1980s! The actual price of Lantus was listed ~$299 a 10 mL vial. The card is good for a year…I’ll see what happens after the card ends.

And now comes the insurance is really bad story: filling a three month prescription for (6) vials of Novalog for three mohths, with ‘Inject 30-60 units daily before a meal’ also written, because CVS requires the exact dosages and ‘(6) vials’ is not good enough for them.

Well - do the math (the pharmacist certainly did): 90 days x 60 units = 5,400 units.

A vial is 1,000 units (100 units/mL x 10 mL).

The pharmacist would only give me (5) vials for 83 days. yet my copay was still for 90 days. At $330 a 10mL vial of Novalog x (5) vials = $1,650, 20% of that is above my 90 max copay so I ended up paying $125 for 83 days. In a year, I will end up paying four x (3) month copays and get only 11 months of Novalog. If my prescription had been written for 30-62 units a day…do the math…62 x 90 = 5,580 - the pharmacist would have to give me (6) vials.

I called CVS to complain. The answer after 30 minutes explaining and explaining again? The 90 day copay applies to any prescription written for 31+ days.

The USA healthcare system is seriously broken. Big surprise.

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