Tresiba Excluded by OptumRX 2018

Hello I currently have Express Scripts to cover my tresiba and Dexcom. My company is changing benefits too OptumRX next year. I saw on there list of accepted drugs and excluded drugs for 2018 Tresiba was excluded. I don’t want to change to anything else but Tresiba. I have good results and would hate to change to try something else because of cost. Can anyone help and provide some help to get this covered. Really worried for 2018.

If you read in the front of the formulary from Optum, you will see the following question about “Exclusion” answered:

What if I don’t agree with a decision about an excluded medication?
You (or your authorized representative) and your doctor can ask for an initial coverage
decision by calling the toll-free member phone number on the back of your ID card.

Basically there is process for you and your doctor to argue that Lantus doesn’t work as well as Tresiba and that it is medically necessary.

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I did see that. How hard is IT to get this to work?

I can’t really answer that. Some insurance companies are sticklers. And some of it has to do with how well you make the case of medical necessity. If you use a CGM and can show how terrible you did with Lantus/Levemir and how well you did with Tresiba then you have a strong case. If you can’t show a difference and A1c and depend on a doctors opinion, then it is not as strong a case.

I do have a CGM but didn’t start using it once I was on tresiba already. So no real data on levimir. Even though my A1C was 5.7 with 6 units of basal. LADA is progressing so up to 19 units of tresiba.

All you can do is try and make a case. Tresiba is particularly helpful for many of us in controlling overnight blood sugar levels. I noticed a dramatic reduction in morning highs due to darn phenomenon.

You may also find it useful to use the Tresiba Savings Card which can give you up to $500/month savings for 2 years. Also you may find that you can stretch things out by using Tresiba U-200.

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I would try to get the doctor to write a letter detailing why you need the tresiba. Good luck. If it isn’t truly medically necessary, I don’t think it’s really going to fly however

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