For a diabetic, choosing health insurance is like walking into a minefield: make the wrong choice and poor coverage could injure or even kill.
The problem is compounded by the FACT that insurers deliberately obscure the details of their diabetes coverage. While improvements to the Healthcare Marketplace now show formularies, actual discounted costs are absent for types and brands of insulin, brands and quantity limits for glucose test strips, brands of insulin pumps and infusion sets, and continuous glucose monitors (CGM).
We can solve this insurance concealment problem as a community by posting (anonymously) our insurers and prescription coverage, along with lessons we’ve learned from struggles with the insurer.
An example: for 2016, my coverage was with the Premier Health Employee Plan in southwest Ohio.
Insulin: Novolog, $75 copay every 90 days for 7 vials
Glucose test strips: Bayer Contour Next, $0 copay every 90 days from MVH pharmacy
Animas infusion sets: $341 copay every 90 days
This coverage is available to employees and dependents; copay amounts may increase in 2017.
Lessons learned:
it’s a new plan by a hospital system, so lots of growing pains/errors
Example of errors: (1) pharmacists who don’t understand insulin pump treatment ignored Doctor’s Rx and dispensed fewer vials of insulin than written on Rx (happened twice) (2) durable medical equipment (DME) subsidiary inexperienced with pump treatment charges different price each quarter for supplies (over 12 month period)
What do you think? Can we help each other by pulling back the curtain on hidden copays? Can we be a community of mine-sweepers for the minefield of health insurance?
I think that you will be able to tap into the hidden copays and frustrations that we all have. However, having been at a number of employers over the years, people need to realize that who they view as their insurance company and what is covered under their plan, is mostly dictated by their employer and not the insurance company. So when someone says I have the “green” plan at BC/BS and they cover this, what most of them should be saying is I work at X company and BC/BS administers the plan, my employer has chosen to offer this coverage to employees. Now, this mostly applies to large companies that self-insure, but even at a medium-sized companies the insurance company offers a very detailed checklist to the employer, and they decide how they want to be insured based on the costs and their business situation.
An example of this from my past. I worked for a large Fortune 500 that offered no coverage for IVF. I had a co-worker that switched companies to the competitor, who used the same insurance company, and called their plans the same thing, but offered IVF coverage.
This is yet another reason why it is so frustrating and complicated to talk about insurance, and why we would be better served by a rational market rather than the gobbledygook of a system we have cobbled together currently. With that said, I feel that currently, no matter which insurance we have, diabetes is going to cost about $200 per month out of pocket. This is because we want access to a pump, the latest insulin’s and CGM. I don’t like that this is the answer, but it is what it is and I am blessed to be able to afford these.
Hi Mitch, I think that’s a great idea. Perhaps you can make a survey where people input this information into categories and a public database is generated. Do you want to sketch out what what survey would look like (what each question would ask? Ie. year of service, employer, provider, beginning of year deductible, insulin copay, etc.). We’d want it to be standardized so the information stays organized, even with varying types of plans. If people are interested in sharing this information and creating a database, let’s make it happen! Best, Mandy
I think I’m one of the lucky ones (at least, at the moment). My health insurance plan is awesome and the only thing I have to pay for is a co-pay for my insulin. DME and my co-insurance are both at 100%, so I pay nothing for pumps, CGMs, or supplies.
It pains me to hear about other posters who have terrible or even no health insurance. I’ve been T1 since I was 7, so I grew up with a serious fear of ever being off insurance. I think it actually pushed me to pursue a career that would have some stability to it.
Chris72,
What you say might be true in your area and with large corporations nationwide but I have had a different experience. I’ve owned my own small business since 1998 and have always been the “buyer” of the company health plan. First of all, there are very few choices for a small business, and the carriers have a “take it or leave it” attitude. Usually the company’s choice of carrier and plan is a balance between network coverage and premium.
Presently we are in a group with similar businesses in order to get a decent policy. We were with them since before my diagnosis and for employee retention reasons I am not inclined to switch. The copays are entirely up to which plan is selected (similar to the gold, silver, etc. on the exchanges but with many more options on deductibles and co pays). We buy what would be considered a cadillac plan, with low copays and a wide network, etc. Those are the only choices the business owner can make…formularies, DME coverage, # of test strips per month, medical policy of the carrier is non negotiable.
Even with all that, I still have to pay 100% of my CGM, the insurer will not cover it. This is based on the “medical policy” of the health insurance company, the business owner has no say in the matter. Yes I have appealed it and lost. I doubt they would approve a pump either. Their policy basically says if you have not been in the hospital for hypos more than once the DME is not “medically necessary” but is a “convenience” (their word not mine). It took me a month of phone calls to get “temporary approval” to exceed 100 strips per month.
My opinion is the best way to get better and more consistent insurance coverage for diabetics is for the state insurance commissioners to do their job and force the insurers to change their “medical policies” that the insurance companies use to deny coverage. These so called watchdogs are not really watching.
I’m relatively new to the forums, so may need some pointers/guidance how to create the survey or database. . .
Here is the information I think would be most useful:
Coverage year (insurance is changing so quickly that 2016 will be most relevant)
Employer group name or individual policy
Insurance carrier
Annual deductible and whether Rx is included or has separate deductible
Formulary tier for specific brand of insulin plus copay cost and/or %
Formulary tier for specific brand of glucose test strips plus copay cost and/or %
Initial Quantity Limits for insulin, glucose test strips, other diabetes supplies
Durable Medical Equipment (DME) coverage for insulin pump, copay %
DME brand preference for insulin pump? (example, UHC & Medtronic)
DME coverage for CGM, copay %
Feel free to add to this list, though I agree the information needs to be standardized to be useful in making comparisons.
To the best of my knowledge, no diabetes organization has compiled this information for comparative purposes. The lack of data makes it difficult for those trying to survive diabetes and it helps insurers avoid accountability for coverage disparities.
This may be a bit provocative, but I don’t think the respective “advocacy” arms of JDRF and American Diabetes Associations are doing their jobs, either.
For example, “both Section 504 of the Rehabilitation Act of 1973 and Title II of the Americans with Disabilities Act (ADA) of 1990 prohibit covered health care and human service providers and institutions from discriminating against persons with disabilities in the provision of benefits or services or the conduct of programs or activities on the basis of their disability.” (See Disability Discrimination in Health Care and Health Services ) Yet, it doesn’t appear either organization has raised concerns about how damaging so-called insurance “managed care” (translation: short-term cost reduction) initiatives are to those with T1D and T2D trying to stay healthy.
Multiple encounters with physicians and insurers have convinced me that all T1D and T2D patients are assumed to be uncontrolled and that assumption translates into self-fulfilling practices.
We need to be our own advocates and show that it’s possible to live long, healthy lives that are less costly when we aren’t denied the support to be healthy. Shared information about insurance coverages can help all of us be healthier.
Mitch, I agree. From what I’ve seen, the companies rely on clinical studies to deny DME coverage for people with good or barely adequate BG control. The ADA seems to go along with this approach in their dealings with insurance regulators which bothers the heck out of me.
For the survey, I think the medical policy of the insurance carrier for DME etc. and the prescription formulary are the key things that vary significantly among carriers and seem to be hidden away “behind the curtain” in everybody’s dealings with insurers. I had to make a special request during my (failed) appeal of CGM coverage just to get a look at the applicable policy. They kept referring to the “medical policy” in their denial letters but it was like pulling teeth to get them to send me the actual written policy.
Co-pays, deductibles etc. are going to be different for everybody regardless of which insurance company we have. In other words, a plan with high co pays or deductibles is an employer choice, the employer could have paid more to get smaller co pays. So that is not really the insurance company’s issue.
Also I think some people will be hesitant to state their employer on a survey in today’s world of online snooping. I would take out #2 and #4 from your list, and also the co pays as I think they would confuse the main coverage problem with health insurance companies which is #5 through #10. I also think that whatever Medicare does the carriers end up following along, and hope that Medicare decides to cover CGM’s before I turn 65.
These are just my thoughts, it’s admirable of you to try to get this survey started…Not trying to throw cold water on it just trying to explain where I think the real problem is with coverage (the carriers medical policies and formularies). Thanks for introducing this important topic!!
Just as a reminder we don’t allow unapproved research or surveys in our community. You may have a worthy goal but we have a policy and requirements that assures that our community is not used for commercial purposes and that we protect our members privacy. A broad study of the clinical policies that relies on insurance company information is certainly fine and would be of value, but member surveys can be of concern. Just be aware of our Terms of Service (see section 7).
