Why does the communication SUCK?

So, as many of you know, our son, Liam, is going to be put on the pump this coming Thursday. So, our doctor put in a prescription for syringes, test strips and vials of insulin to get us prepared for the transition. My wife goes to pick up the prescription and finds out that the cost is $268 for a 30 day supply of the Humolog insulin. …???

So, she asks if it would be cheaper if she purchased in 90 day supplies and the tech there said he didn’t have that information, that it would be something we’d have to investigate with our Insurance. So, she doesn’t fill the prescription; instead, decides to come home to call CVS Caremark (our prescription insurance company) and ask them about it.

Come to find out, FIRST, Humolog isn’t even “preferred” within our BCBC plan…but Novolog IS. SECOND, although the 30 day supply costs $268, if we fill a 90-day order, we would only pay $200!!! This is because there is a “cap” on the amount we pay for prescriptions >= 90 days.

So, this is where my confusion comes in and why I feel communication sucks…WHY would the medical Endo team not be able to communicate with our Insurance to find the PREFERRED medicines, to determine which plan (30, 60, 90 day, etc.,) would be CHEAPEST and THEN submit a prescription for our son based on that information? Why do we have to find out the hard way that the info sent over by the Doctor is the most COSTLY of all options??? They submitted a prescription for Humolog, 30 day supply (not-preferred, no cap associated), instead of a Novolog, 90 day supply (preferred AND has a cap of $200 associated with it.)

All this time it appears that we could have been paying LESS each prescription with our MDI had we known that Novolog was “preferred” and the Insulin we are currently using, Humolog, isn’t.

The lack of communication all around just makes me more frustrated than I can even begin to express.

It’s good that we found out this information now…from all that I’ve read on this forum and others, Novolog seems preferred over Humolog anyway…it still doesn’t make the Insurance to Doctor and Visa Versa communication issue any less frustrating.

– END OF VENT –

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I’m surprised we aren’t all bald from tearing our hair out over insurance issues. I know your pain.

Unfortunately it’s your insurance, not the doctor’s. We have to be more proactive. I have the same problem with all of my meds - figure out what’s covered before we get an rx (big pain when getting a new rx for a simple antibiotic or blood pressure med). I have wars with my insurance over test strips (the preferred ones are $1200 every three months with my high deductible plan) and Humalog is the only insulin covered AT ALL. Get a formulary if you can so you know what’s covered with your plan. Even with the formulary, it can be difficult but at least it’s a starting point.

I’m surprised you didn’t know - what were you using before the pump switch?

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We don’t know we NEED to be proactive until something like this happens. One would think that between the two of them…the Insurance, and the Medical profession, that ONE side or the other would look out for the patients…

Now I know…but it doesn’t mean I don’t believe the system is flawed.

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I’m confused as to why anyone would think I WOULD know?? I believe what my Insurance and my medical team tells me until I figure out that I can’t trust them to look out for our well being. I think the best of everything, and everyone, until such time that I figure out I shouldn’t…this is case in point. Lesson learned now.

Again, though, I don’t agree that it should be MY responsibility (someone with zero medical knowledge) to figure out this type of information. It would be a simple conversation between the medical team and my insurance.

Medical team: “So, what Insulin is preferred?”
Insurance: “Novolog”
Medical team: “Okay, so what’s cheaper, 30 day or 90 day prescription?”
Insurance: “90-day”
Medical team: Thanks.
Insurance : No problem.

Medical team calls me: “Insurance said Novolog is preferred and 90-day will be cheaper, so I’ll be writing your sons prescription for this. Okay?”
Me: “You’re the experts. If it’s the best and the cheapest…I’ll take it.”
Medical team: “Great. Done.”
Me: “Thanks.”

Both conversations took 15 seconds…

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Oh my gosh ! Same experience here. Thought the Dr and or the medical Team would help me with that too, but NO!
It’s like you have to find out by yourself.
In my experience I got new job therefore new insurance, with previous insurance I was paying only $35 for one box 5 vials of Humalog monthly. With new insurance went up to $250 for every 3 months “most affordable” but if I wanted monthly supply would cost me $200 a box of 5. But that’s not the worst part. I would be getting less insulin if choose to get the 3 month supply. So I strongly encourage you to not get discouraged and second keep asking to your Medical Diabetes Team. I’m sure they’ll help you.

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We were told Humalog is typically cheaper than Novolog and that most insurance companies required patients to “fail” treatment on Humalog before they’d approve a Novolog script, so our endo put us on Humalog for months using that rationale. So I’m guessing your doctor thought Humalog was cheaper. There should be some folks in the doctor’s office who can ask that question, but my impression is taht until you submit an actual claim, they can’t quote you a price. Honestly, I think the whole insurance process is like a magical black box where in goes the prescription and poof, out comes a price, and no one – including the insurance company itself – can actually explain what the likely outcome is going to be until after it’s entered into the box. Very quantum mechanics, and SOOO frustrating, I concur.

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I share your frustration… But the sooner you realize that you’re you only (and your child’s only) advocate the better. That’s just the reality of the situation.

You will have to become an expert on this situation not only in terms of day to day management, but also in how your insurance works— I wish there was better coordination between practitioners and insursnce-- but the reality is both of them just consider the problem as the others’ dysfunction. Did they even explain to you that the cap on 90 day prescriptions is only if you use their own mail order service? It is…

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And remember what @Alejandra_Urano said

Sometimes the 3 month supply is not enough!

So be certain to ask doctor for a three month supply which is really a 4 month supply.

For sick days, etc.

He’s so small right now we’re fairly certain that each vial will be more than sufficient AND have some left over to use well into when the next vial should be started up. He’s, right now only using Lantus + Humalog between 3 - 5 units per day.

We will be hording everything we can get our hands on, though, for a) rough days when I may lose my job and/or b) a zombie apocalypse. We’ll just make sure we’re always using first in, first out.

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Any Doctor worth a damn will over prescribe insulin to anyone who has the cognitive ability to do anything more complex than “take exactly as directed”

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I work with a medical team. Conversations with insurance never take 15 seconds!

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Just got off of the phone and requested clarification on this point. In our case at least, both pick-up AND mail-in are the came cost and the cap applies to both.

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Is that if you pick it up at a cvs pharmacy?

I have Caremark tooWe don’t have CVS locations where I live, so my choices are pay whatever the cost is for a 30 day supply at a local pharmacy (no limit) or go through mail order and with my plan it’s a $75 limit for a 90 day supply with mail order.

Providers are pretty well trained up when they hear the word Caremark to write for 90 day supples (I always assumed this always meant for mail order but that may be a function of where I live as there are no cvs nearby)

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Check your insurance website and see if they offer a ‘what’s my copay’ section. The last couple of insurance companies I have had provided this, which meant no calling insurance and waiting on hold. You just type in the drug, amount you will be using and then which pharmacies you want to compare prices of. It will also notify you if something isn’t covered. I try to do this at the first of the year and before appointments if I think I may have a drug change to save the headache.

Also, you’re actually kind of lucky it’s Novolog! They have a copay card which can get you a vial for about $25 depending on your normal copay. Only caveat is I think it only works for a 30 day, not 90 day supply?

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Initiation into the world of chronic illness is hard, but learning to navigate the world of insurance is a nightmare of a new kind. My first trip to the pharmacy after my daughter’s dx ended with me siting in my car alone in the parking lot crying. It was the first real crack in the facade of courage I had stood behind. $1700 for 30 days of life. I couldn’t imagine how we would be able to keep her alive for long. I called the insurance rep & got no help at all. My husband’s HR dept had no answers. 6 months later & with a much smaller savings, during a call to verify pump brands covered, I lucked out. The CSR I spoke with happened to be a fellow d-mom. She explained that under our plan all D supplies were DME & could not go through pharmacy. By the end of the call I was much more educated, had a benefits booklet (never before provided by anyone) on its way, & an assigned case manager who I could contact with questions in the future.

Lesson learned: know your coverage & formulary inside out. I carry a .pdf of our drug formulary in my phone at all times. When one of my daughter’s many providers mentions a medication, I immediately search the formulary to make sure it’s covered.

To be fair to the drs/clinics, it’s asking a lot for them to verify coverage for every patient. It’s a bit more complicated a quick phone call.

I feel for you. Trying to learn the insurance rules when they’re ever-changing adds even more stress to caring for our kids.

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In that case, absolutely use your local pharmacy for insulin & get that Novo copay card. You can also get the Freestyle copay card for strips since you’ll be on the Omnipod.

ETA: Freestyle Promise card

Novolog copay card

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That’s a good point…sometimes you have to call five + times before you get someone who actually knows what they’re talking about and can help! Don’t be afraid to keep calling until you find that person and when you do, get their name and extension because they are few and far between. :angry:

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Yes. CVS, which is right down the road from where we live. So it works out.

Question for anyone that uses Novolog with the pump…is the Novolog we will be getting for our son’s omnipod one of the below? I’m thinking the bolded one maybe?

Offer Details: Pay no more than $25 (up to $100 discount) when you start on a Novo Nordisk product and for each refill for up to 2 years, and no more than $20 (up to $100 discount) for the next prescribed product and each refill for up to 2 years. Offer available for a 30-day supply of Levemir® FlexPen® (insulin detemir [rDNA origin] injection), NovoLog® Mix 70/30 FlexPen® (70% insulin aspart protamine suspension and 30% insulin aspart injection, [rDNA origin]), and NovoLog® (insulin aspart [rDNA origin] injection). Offer is valid for a maximum of $100 off your co-pay for each 30-day supply for a maximum of 24 refills per product over 2 years. Novo Nordisk reserves the right to modify or cancel this program at any time.

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