Yesterday I received the new guidelines for my 2017 Medicare Part D supplement along with a copy of the new formulary, and here we go again. Neither Apidra nor Humalog is covered, only Novolog. Novolog is my last choice of the three, as for me it has a much longer tail. So once more I’ll be shopping for a different plan. I was unhappy that last year of the 24 plans offered in my area, only one covered Apidra (my first choice) and that one only as a tier 4 drug. It would have cost me $1300 more a year with that company than enrolling in my current plan with Humalog as the only choice.
Since I’ve been on insulin, I’ve had to change my Part D plan every year to try to get one of my more preferred insulins. Some plans cover Levemir but not Lantus, too, so that’s another consideration. And even if one changes plan to get a desired drug, they can still change the rules of the game. One year I changed to get Humalog, and by the time I needed to refill a prescription in February, the company had already changed to Novolog.
Anyone else having to go through the same thing this year?
Yes, me. Apidra is by far the best fast acting insulin for me. It was dropped from the formulary LAST January 1, so I’ve been buying it at retail all year, waiting for this Fall when I can find another plan. I feel your pain, absolutely.
I go through this every year, but not on Medicare. One year, they’re fine with Humalog, the next they insist on Novolog. One year, Apidra is fine, the next year not. There’s obviously no medical logic to what is covered, I assume it’s all about which company gave the formulary the best price for the next 12 months. If you have a problem, then you can waste some of your doctor’s time with a exception letter. Sounds efficient, right?
Agree w @David_dns re Apidra, though I know others here will say Afrezza is faster, so Apidra is the fastest injected insulin.
The formulary in my prescription drug plan, a policy I earned as a retired employee, favored Novolog starting last January 1. When my doctor appealed based on my allergy to Novolog, my Apidra coverage and supply continued.
Since these plans are so capricious with their formulary and can change at any time, perhaps appealing is a better course. My allergy assertion was simply a report I made to my doctor when I became her patient. I observed allergic symptoms years before I became her patient.
What I’m trying to say is that my simple assertion combined with the appropriate note in my record is all it took for the insurance company to relent and grant my appeal. I don’t like business decision values interfering with the clinical relationship I have with my doctor. I would not see “fabricating” that circumstance as an ethical lapse so that I can use the insulin that works best for me.
I use a pump and the allergy symptoms with Novolog were silver-dollar diameter raised and red bumps at the infusion site. If I was forced onto Humalog and found it less effective I would make any claim needed to get insurance coverage of Apidra.
Thankfully, I had a good supply of Apidra in January, five or six insulin pens, when the new supplement year started. And after I complained to my endo that with having to use Humalog, I’d have to wait up one more hour before feeling safe to test and go to bed, he gave me three more pens of Apidra from his sample stash.
So what I’ve been doing this year is to use the Humalog for breakfast and lunch and for any dinner that was so low-GI that the Humalog curve more closely fits the BG curve than did Apidra. That way I have been able to use Apidra for the majority of my dinner meals this year even though Apidra isn’t covered under my current plan. Thus I’ve been able to stretch what Apidra I do have on hand out for most of the year. I’m on my last Apidra pen now, so I’ll run out before the end of the year.
I’m hoping that I’ll be able to find a supplement that will cover Apidra as a tier 3 drug for next year, but am not too optimistic. I can see if my endo will give me any samples when I see him next month, but without starting out with any on hand, a few samples won’t go too far at covering dinners and corrections.
I’m a bit hesitant to ask my endo to go through the paperwork for an exception. He was obviously a bit perturbed going through all the paperwork to get me six test strips a day. He’s keeping me on as a patient so I can get the extra strips, but he says I really don’t need an endo. However, my PCP refuses to do the paperwork for extra test strips, as do most of the other PCPs in this area, according to my endo.
His hesitancy makes sense in light of the fact that the payers (insurance companies) are needlessly foisting upon doctors an avalanche of paperwork that distracts him/her from his/her core clinical duties. But patients are not to blame for this and should not suffer as a result. The whole system is a cry for help. It totally undermines the mistaken belief that the the U.S. has the best healthcare system in the world.
I don’t know if this will help…but are Apidra and/or Humalog available in Pen form? Are you one a Pump? If you are on a pump, I have read some people who can’t get Humalog vials, (I don’t know about Apidra ), use the pens to fill their reservoirs…Usually Humalog VIALS are taken off Medicare providers fomularies, but the Pens are covered on the plan…Just an Idea…If they have stopped both Humalog vials and pens along with Apidra, that that is just unfair…I just read an article About the CEO of Lillly, (the makers of Humalog), justifying the cost increase in Humalog Insulin as necessary to fund new research, and that there will be more increases into 2020 upwards of $800 per vial, ( My medicare just paid $885.94 for 3 vials of Humalog yesturday)…It’s outrageous what Insulin is costing…
So Terry, you use Apidra in your pump? I read some great things about it recently on the Beyond Type 1 site, but somewhere in there they mentioned it’s not approved for pump usage, though people do it. I’m interested in trying it but don’t know if I’ll run into problems with my endo prescribing it since she knows I use a pump. Do you have any problems around that?
I live in an area where most of the endos are pretty busy. At the time I was referred to this one, some endos in this area were not taking any new patients at all. And those that were, only accepted patients whose A1c’s were running over 7.0. Since my A1c has been between 5.5 and 5.9 the past three years with MDI, I strongly suspect that most endos here would prefer to let my PCP handle it. As it is, I have to go 80 miles to see this endo.
It took 15 minutes to fill out the paperwork necessary for the test strips. That’s the total amount of time I suspect was allotted for my appointment, and he hadn’t even begun going over the things normally covered in such an appointment, though he did go on and do the other things, also. We know that Medicare does not reimburse specialists for their time anywhere near what they get for time spent with their younger patients. And I saw on one website that 80% of my endo’s patients are over 65. So I totally “get” the irritation he might have with governmental interference in how he conducts his practice. He also has to keep my logs of BG and send copies of them to Medicare periodically to continue to justify the cost of my strips. So that takes time of his staff, too, between appointments. Medicare likely wants patient and/or doctor to feel it isn’t worth the trouble so they won’t need to pay for extra strips. But a limit of 3.33 test strips a day for a type 1 without the extra work is a bit ridiculous.
Not sure as to the source for this but the Apidra package insert notes that Apidra may be used in a pump but they warn to change the pump reservoir and infusion set every 48 hours.
I’ve been using Apidra in a pump for about 10 years. I often use it for three days at a time with little trouble. I do have indications once in a while that my site absorption is getting tired. This could also be a partial occlusion caused by Apidra/infusion set interactions.
If I have any unexplained hyperglycemia, especially on the third day of a site, I will quickly swap out the site, but that seldom happens.
The package insert does say that you can’t mix Apidra with another insulin or dilute and then administer via the pump.
I have read that Apidra does not work well in a Tandem pump. Whether it is the type of reservoir or the heat generated from recharging the pump, it has worked poorly in that pump. I think it gels for many users.
I have used Novolog ever since I started pumping 12 years ago. I used Humalog before that and didn’t notice much change when I switched. I have experimented with Apidra a couple of times and didn’t notice enough difference to switch since it was not on my formulary and it would have required an appeal to use it. I have never had insurance that had Apidra on the formulary.
So I will be relatively lucky moving into Medicare because I don’t care which short-acting I use (as long as it is not Regular!). I know that each insulin might require different settings on my pump and different pre-bolus times, but I feel that I can adjust.
I was on Apidra since 2009 and thought it was the holy grail. Cigna now only pays for Humalog and Novolog. My Humalog trail was a disaster. Novolog seems to be about the same or maybe even better than Apidra. YMMV.
Thanks for the info on the Tandem pumps incompatibility with Apidra, @Laddie. I use Apidra in my Animas Ping pump. It’s nice that you can use all three of the current rapid acting analog insulins now on the market.
I ran into bureaucratic entanglement when I tried to get Walgreens to cover my insulin under Medicare Part B. Medicare technically covers insulin and test strips for people using an insulin pump. I decided to save myself the hassle and acquire my insulin under my mail order plan I receive as a benefit from my former employer. I’m thinking about tackling the Part B insulin issue again since it would save me a significant copay. Do you intend to get your insulin under Part D or Part B? I forget whether you use a pump or not.
Here’s some news. Medicare doesn’t reimburse for anything at close to what it actually costs. Our city provides an ambulance service (we have to, under state law), and it can’t charge anything like what a transport actually costs. The city’s subsidy of the service is now around $300,000 per year and climbing steadily, because each year Medicare cuts back further on their reimbursement. It’s now less than fifty cents on the dollar compared to where they originally started, and getting worse.
I have talked with the pharmacist at my local Walgreen’s and he was familiar with purchasing insulin under Part B. You must use a pump to be eligible for that benefit. For the most part, it seems to be an incredibly unknown benefit for pump users and Medicare plans don’t seem willing to share that info. Pharmacies are reimbursed horribly under Part B and many are unwilling to dispense Part B insulin. It is a huge cost savings and Part B insulin is not counted towards donut hole expenses.
Insulin-pumpers.org is an antiquated email forum format, but there are many members of that group who are very knowledgeable about Medicare. I think that I have seen a phone number shared that is a central Walgreen’s phone number for a pharmacist to get info on filing for insulin under Part B. Might be worth checking out.
I will go on Medicare starting April 1, 2017. The info on the 2017 plans is starting to be released and it is now time for me to start getting serious doing my homework. Although I tend to overthink things, I am finding the “correct decision” to be very complicated.
I was getting my test strips under Part B from Walgreens and the local pharmacy tech kept telling me that “Medicare” was not responding to them. I finally figured out that “Medicare” was really the central Medicare desk staffed with Walgreens employees that was slow walking things. Once I started calling them directly I was finally able to shake loose some strips. I think that Walgreens central office is in Illinois.
In the three years I have been on Medicare (and on a pump), both Publix Pharmacy and Sams Club Pharmacy would not cover strips and insulin under Medicare Part B because the reimbursement is so unfairly low (and less than injectable insulin under Part D). I have fortunatley been able to purchase both at Walgreens without a problem. Well, that’s a bit of a stretch! The scripts have to be renewed every 6 months, a hassle to the pharmacy, my endo and me. I guess, a small price to pay for life!
I also am currently getting my Humalog from Walgreens under Part B. I have so far not been able to get them to bill my secondary insurance: the otherwise very helpful and pleasant head pharmacist had told me with the first order that there was no way to do that. But the copay was something like a fourth of what it had been billing it under BC/BS, so I just paid it, thinking I would try filing it on my own later, but never did. As I came home from picking up the second order at Walgreens, 3 months later, there was a letter in my mailbox from Walgreens with a check for the copay I’d paid for the 1st order, telling me my secondary (BC/BS federal employee) had also paid, and I should give the pharmacy the BC/BS info, which, of course, I had given them the first time.
I decided to pursue the PartB possibility when my copay under my secondary plan (which takes the place of a Part D) had gone up to more than the over-the-counter-without-a-prescription full price in Canada, and the news said it was going up more. My local CVS had said the Part B wasn’t possible. The next closest CVS did, after a lot of back and forth with the endo, get me 1 order, but couldn’t seem to continue it! Not to mention them telling me that the reimbursement they finally got from BC/BS could not be returned to me, even though they’d made me pay it to get the insulin. I went to the particular Walgreens on referrals from a pharmacist and a geriatric social worker, and, even though it’s farther, it’s only every 3 months, and it’s actually nearer my endo.
If I didn’t have insurance, it would be quite a bit cheaper to take a plane to Canada every few months than to pay for insulin here. (Wonder what prices would be in other countries.)
The Walgreens phone number that handles insulin and strips for Medicare Part B is 217-554-8766. If you use a pump, insulin is a Part B expense. If the local pharmacist says that insulin isn’t covered under Part B, have them call that number.
The Medicare approved amount is extremely low - $36 for a vial of Novolog. Part B covers 80%. If you have a Medicare supplemental plan (as opposed to a Medicare Advantage Plan), they should cover the remaining 20%.
