I got denied twice for my Tresiba. I am currently writing a letter to an independent review board. Does anyone know what are good source of appeal letters? I want to know should I provide information on why tresiba is better that troujeo and Lantas? Or do you think that is necessary? I have tried the troujeo and the burning sensaition on injection and the uncontrolled blood sugar should of been enough for the first appeal, but it wasnt. So here I am trying at my last oppurtinuty to save my health.
Is your doctor involved? Are they applying for a medical necessity use for you?
Both my Endo and General Dr have written letters. Now I have to create my own for the independent review board.
@borijess I don’t have any suggestions for you, but offer you the best of luck! I know when we find something that works we want to stay with it; it is miserable when we’re forced to change to something which doesn’t work or can even makes it worse.
If you have commercial insurance, this might be of help:
If your insurance covers Levemir or would prefer that to Tresiba, you may honestly need to try that first. I had to document that I’d tried both Lantus and Levemir to get Tresiba approved. For me, Levemir caused an allergic reaction, so that was a non-starter, though honestly, if it hadn’t, I think it would be a better choice (more adjustable) for my case than Tresiba anyway, but ymmv.
This novo offer can help with or without insurance. I use the $99 offer for novolog as a “cash pay”, since my insurance does not cover novolog (insurance switched to humalog for 2020, hoping they switch back next year).
The $99 offer covers 1, 2, or 3 vials month, for $99.
$198 for 4, 5, or 6 vials.
Offer may end at year end, hoping they will extend or start new offer next year.
(Check details for pens).
Follow the option for
In link provided in @Tapestry post.
With this program, pay $99 for a monthly supply of any combination of Novo Nordisk insulin products (up to 3 vials or 2 packs of pens). Offer is available each month during a calendar year. This cost does not apply to any insurance deductible you may have.
You should be able to download the “primary drug list” for your insurance. There are generally not any forbidden medications with insurance, but rather they have preferred ones you can get without jumping through hoops, and other ones that are not preferred require “prior authorization”.
The preferred drug list should provide notes on what is required to achieve prior authorization from the insurance company. In my experience, it usually means you have to have tried all of the preferred drugs, and the treatment options “failed”. My doctor says it’s pretty easy to declare treatments as “failed”, if you really want a non-preferred option. Side effects like pain and/or irritation, nausea, or allergic reaction count; as do things like inability to comply with the prescription (a drug that requires 2 injections instead of 1 might mean you’re not able to take the second dose appropriately), and not being able to achieve treatment goals with the preferred medications.
There should be an online physician portal for your insurance company, where the doctor logs on to complete a prior authorization request (PAR), answers the questions, and submits for approval. Done this way, it shouldn’t take more than a few days for a response.
This writing letters thing doesn’t sound like an appropriate nor effecient pathway. Letters don’t mean a thing to insurance companies, except for maybe when you’re contesting a decision. The paper pushers only want to push very specific papers. Everything else gets filed in the trash bin. Why is your doctor writing letters instead of filling out the PAR?? If they did fill out the PAR and you got denied, I’m assuming it’s because you haven’t met the conditions specified in the preferred list and your doctor needs to briefly prescribe the other options first.
My work and insurance tell me this is the process.
I’m with @Tapestry. I think that is the easier route.
What @Robyn_H is saying, is that you are searching for the TIER 1 medications listed in the policy. That’s what gets covered without jumping through hoops. You want to know what tier this med is in. If the Doc wont sign off, then you might need a different doc.
I like Levemir as an MDI basal - lots more than Lantus - but for me it required 2x per day and probably could be even more fine-tuned at 3x/day. I use Tresiba now, which is a different beast altogether, much longer acting, 1x/day, and for me therefore also requires a little different approach to bolusing details.
When they have “made” me switch in the past, I had to try the insulin on their preferred list. They would not cover it unless I tried the other. I let my endo know it didn’t work as well and she then got it okayed. However I did have to pay a higher copay because of it not being on the list.