I have Wellcare as a Medicare Part D plan. I selected them due to not many Part D plans covering Omnipod and Omnipod suggested them as one who covers it. Back in November I called Wellcare and asked if they cover Omnipod and Novolog. I was told they cover Omnipod and Insulin aspart, which I understood to be a generic version of Novolog so I selected them.
Turns out the only insulin they cover is Fiasp, and from everything I’ve read on here and other sites Fiasp is kind of hit or miss on reliability and some experiencing side effects due to the additives. My doctor also has said this so he sent a pre-authorization request to get Novolog covered. They denied it literally two hours after he sent the request. If Fiasp works then fine, but now I cannot stop thinking what I’m going to do if it does not work or I have issues with it.
Anyone have any suggestions or are in a similar situation? I am sickened that insurance companies dictate medications when it comes to life depending drugs.
Can you please tell me what Wellcare plan you have? I too have Wellcare, but was told that the Omnipod was not covered. Novolog was discontinued. I was offered Tresiba. So far I am very pleased, but I would really like to try the Omnipod, so if I truly not covered on my current Part D plan, I would switch next year. I also believe that the Omnipod is not set up for the Dexcom G7, but perhaps it will be soon. Please, if any of you can help me here, please chime in. I am so ready to use use an Omnipod. Many thanks in advance.
I’m sorry you are stuck in the this situation. This is a terrible way to lean you have to read your plan formulary every year.
Read about how Part D appeals work:
I did a couple quick searches in the appeals database. No one has gotten an appeal approved for a non-formulary insulin without first trying the formulary drug. If you want to try to avoid trying Fiasp your doc could try the reason is Omnipod 5 isn’t labeled for use with Fiasp. Important Safety Information | Insulin Pump Therapy | Omnipod and Omnipod 5 Manual page 8. Note Insulet isn’t going to back you up on this, their FAQ says Fiasp was tested and is okay.
I’m not sure how Wellcare works. But I know with past insurance (it was before Medicare) if your insulin of choice is dropped, they want you to try the one they cover and if it doesn’t work then your doctor can send in an appeal.
So I had to try Novolog instead of Humalog. In my case with my doctor I told her I didn’t like it as well as I was dropping too much hours later at night. My doctor sent in the appeal and it was approved. I did have a copay at a higher tier rate, But that was before Medicare and with a regular insurance plan.
I suggest you have a good back up supply, so you can have it to switch back too if you need to when you try the new insulin. I am one of those that Fiasp is like using water, but I know plenty of people, most in fact, that Fiasp works fine for them.
Thanks for that info. Yes, in the denial they stated I had to see if Fiasp works and if that doesn’t work then they also cover Novolin and I have to then see if that works. Novolin! The $25 Walmart insulin. Uh, no thanks.
Maybe before panicking you should try Fiasp. It is Novolog with additives to make it start working faster. I like Fiasp quite a bit and don’t have the pain or skin issues that I had with Lyumjev. Lots of people really prefer Fiasp to Novolog and maybe you will too.
I use a Tandem pump which doesn’t play nice with Fiasp so I have to change my cartridge every 2 days. Tandem pumps run warm and have a funky insulin delivery system which either cause Fiasp to lose potency or occlude. I do not think that Omnipod users have that problem with Fiasp.
I use Fiasp and Novolog interchangeably. I think Fiasp works better but I hate changing my cartridge every 2 days. Although I always change my site every 2 days, I can use the cartridge for 4+ days with Novolog and prefer that.
Sometimes change is a good thing and maybe Fiasp will be that for you.
Not about panicking as I have about a 6-8 month supply of Novolog. It’s about a corporation dictating which medications I can or cannot take to keep me alive. Yes, Fiasp may work, and if it does work as well then fine, but as of now with Novolog my last A1C was 4.9 with a 97% TIR. I was actually going to give Fiasp a try last year because I loop with AAPS and I wanted to see if I could achieve a completely automated hands off loop, but I decided against it after researching Fiasp and seeing all the problems people were having with it.
And yes, I have seen Omnipod users having the same issue as you are describing.
I think that part of the “price” we’re paying for the $35 cap on insulin prices is a reduction in the number of insulins on formulary. It still surprises me that a company that covers Fiasp wouldn’t also cover Novolog since it’s the same company.
And I know since you’re looking for Omnipod coverage you’re limited in the choices for a Medicare plan. I feel fortunate that I hated Omnipod and use a tubed pump. Much cheaper on Medicare. I’ve had no formulary problems with Medicare Part B insulin coverage. But I’ve read of some people saying that Medicare would only provide “xyz” for them.
Sorry to hear that some Omnipod users also have problems with Fiasp.
For sure insurance shouldn’t be dictating our healthcare options but that’s the American way…
You hit the nail on the head. I think insurance companies are retaliating against the $35 cap, and since Novolog and Humalog are the most commonly used insulins what better way than to drop them for your plan. When I checked in November Wellcare covered Novolog, now they don’t.
USA Today had an article that stated at least 10 out of 22 Medicare drug plans have dropped at least one brand of insulin from their formulary.
First, I congratulate you for your vigilance and determination in managing your T1D. An A1c of 4.9% along with a TIR of 97% (what are your range limits?) are exemplary.
I totally understand your backup supply in the 6-8 month range. You have found a formula where you have tweaked several fussy parameters and made it work for you. Having money-distracted insurance interests interfering with your successful system is annoying to say the least.
I share these values with you. With someone who enjoys these performance characteristics, I guess that you have a particular eating style. I only mention this because I’m aware of a similar and highly successful, yet smaller, portion of the T1D population who use and prefer using Regular (Novolin R is Regular insulin) as their main insulin. Many of them use MDI but some are using pumps and algorithms.
I suggest that you consider trying out some Regular in your pump. You may find that it better fits the longer action curves of fat and protein, especially when carbs are more limited. I appreciate that your AAPS algorithm has made your life easier as I use DIY Loop, different but related.
I only use one vial (1000 units) per month. If you try and like Regular, you may be able to buy your monthly insulin supply comfortably out of pocket and rid yourself of the insurance nuisance. Just a thought.
I really appreciate our choices, but when you control prices, your choices are generally going to go down. When they bargain with a company for pricing, one side has to be willing to say I won’t pay that price or the other side has to say it won’t supply it at that price. This seemed to happen years ago quite often. I remember for a few years it was Novolog, then for a few years it was Humalog and back and forth.
Before Medicare when it happened under my old insurance with an appeal you could pay a higher tier price if it wasn’t under the regular formulary. I have wondered what the cap of $35 insulin rule would cause as I think? it might mean they can’t offer an insulin to you at a higher price? Or because they do offer a couple at the $35, they can offer others at a higher price? I’m just not sure how it works now. So I am curious how or whether an appeal works under Medicare now. And it’s possible if they haven’t bargained with that company to supply it cheaper, they don’t want to supply it at all type thing.
Other countries choices for the drugs they supply, cancer drugs, insulins etc are much more limited because of price control/bargaining. I already know a few people here in the US in the past recent months that their choice of drug was dropped and they are scrambling, one of those person’s drug cost them $800 a month for a couple of months until they could switch to a plan that covered it. She paid it as it made a huge difference in her heart working better.
It is unlikely that a formulary exception would be $35/month but the issue is so complicated even CMS adds a vague disclaimer.
PDF Frequently Asked Questions about Medicare Insulin Cost-Sharing Changes in the Prescription Drug Law
Under a Medicare Part D prescription drug plan, if an insulin is a covered insulin product, the $35 cap for a month’s supply for each insulin product applies, as of January 1, 2023. A covered insulin product is one that is included on a Part D sponsor’s formulary. This includes any new insulin products that become available during the plan year. An insulin product might also be considered covered in other instances.
PDF Parts C & D Enrollee Grievances, Organization/Coverage Determinations, and Appeals Guidance page 31
Unlike under the tiering exceptions process, the regulations do not specify what level of cost sharing applies when an exception is approved under the formulary exceptions process. Instead, a plan sponsor has the flexibility to determine what level of cost sharing will apply for nonformulary drugs approved under the exceptions process. However, a plan sponsor is limited to choosing a single cost-sharing level that applies to one of its existing formulary tiers.
So if the appeal gets approved can @Baddog40 afford the medication? Worst case for the Wellcare Classic Part D plan looks like a 48% co-pay. Is anyone on Novolog willing to take a look at their part D claims for 2024 and share what the “plan paid” price per 100ml vial works out to?
Hi Susan if you have medicare part d you must have Medicare part b. This Is just a thought with Medicare part b I got my tandem x2 pump no cost to me I get all infusion sets a 90 day supply no cost to me I get my insulin aspart aka novolog 9 bottles for pump this is a 90 day supply for $105.00 or $35.00 a month what ever you like. You should look into it. Good luck Oh I have been a diabetic for 65 years and this has been the cheapest I have got away with pump and supplies. Again the best to you Al Olmstead
It would do you good to try to sympathize with other people. Some people prefer to talk to people instead of reading websites. It is not unreasonable to call the company to ask their employees questions.
To the OP: I have WellCare, and switched from Humalog to Novolog last year because of their coverage for the latter and not the former. Now this year I got the same letter you did, which unfortunately does not spell out clearly what the alternatives are. But they do have an identical replacement.
I just filled a replacement for the Novolog, and you need to ask for generic Insulin Aspart. You may or may not need a new prescription from your doc, depending on how they wrote the prescription (I did not need a new prescription). This is a direct replacement for Novolog, with the same action time, if you are not interested in Fiasp.
When you feel a need to write at least 10 paragraphs to argue that you possess empathy my guess is you probably don’t. Medicare programs are not the easiest to navigate so I’m not sure what your point is with your comments other than attempting to demonstrate your own perceived perfection and superiority.
