Common issues around insulin, insulin pumps, CGMs, and test strips
Insulin issues
Tiering issues
Insurance plans group medications into health insurance tiers that determine patients’ access to and cost for their therapies. You can find this information on the drug formulary, a list of covered medicines and their associated tiers. It’s important to know that insurance plans don’t always cover every available insulin, and yours may not be covered. You will need to check the formulary to see whether your insulin is covered and, if so, on which tier. It is important to check this, because it can impact not only your coverage, but also your out-of-pocket costs.
Typically, lower tiers include generic or preferred medications, and higher tiers will include non-preferred or brand-name medications and specialty therapies. Lower-tiered medications are also more affordable, with lower out-of-pocket costs than higher-tiered medication. Your insurance company can change the tier your medication is on from one year to the next. If this happens, you will usually be required to pay more for your treatment. If your preferred insulin is not covered, you should apply for an exception. See more information and tips in How to Apply for an Exception.
Cost variation by pharmacy type
Many times, costs can vary depending on how you purchase your medications. Be sure to understand the difference in costs for mail-order or in-person/retail pharmacy prescriptions. If you prefer to pick up your medications at a retail location, it may cost you slightly more than if you used a mail-order store.If you find yourself paying more than you would like, you may consider looking into discount programs that can offset your costs. Some medication manufacturers provide financial assistance programs that can help with co-pays for those who need help to afford their treatment and supplies. Each program has specific criteria that must be satisfied for an individual to be considered eligible for a patient assistance program.
You may want to keep in mind that discount programs may result in your purchase not applying toward your health insurance deductible. Because your costs will likely decrease after your deductible is met, you may want to consider the timing of your purchase to align with when your deductible has been met so more of your costs will be offset by your insurance plan.
Aligning prescription needs
Different people use varying amounts of insulin. For example, a vial of 1,000 units will last only 20 days for a person needing 50 units per day. In this case, the person would need to ensure that the prescription is written for more than one vial each month, to avoid paying multiple co-pays for a month’s worth of insulin. Make sure you plan ahead so that you have enough supplies and insulin, especially to cover yourself in the event of a vial breaking. Speak with your doctor to ensure that your prescription gives you the right amount for your needs.
Understanding that different insulins are treated differently by my insurance company helped me ask the right questions and get a treatment that suited my condition and my budget.”
Test strip issues
Quantity limits
Some health insurance plans limit the number of test strips you can obtain during a specific time period. You can find this out by checking in two places:
- The formulary for your plan
- The specific policy related to testing supplies
Make sure to check the areas that discuss tiers and associated costs and determine if your costs differ for mail-order or in-person prescriptions. Even if there is a limit, it is sometimes possible to get more strips to manage your condition by applying for an exception. When applying for an exception, you will need to document the number of test strips you have been using.
Insulin pump issues
Requirement to align with plan criteria
If you are not currently using an insulin pump, insurance companies will usually require you to meet certain criteria before they will cover the cost of an insulin pump. This may involve your doctor completing a prior authorization (PA) or pre-certification form, which will include evidence of medical necessity for an insulin pump: the frequency of testing needed or your hemoglobin A1c (HbA1c) levels.
In addition, insurance companies may require that for some types of insulin pumps, like the artificial pancreas system pumps, patients must use a pump without an advanced feature for a period of time before switching to the more complex or advanced pump. In this case, your doctor may need to provide details of your previous insulin pump use prior to you receiving coverage. Insulin pumps are covered under a special section of your insurance plan known as the durable medical equipment section. Be sure to check this section to ensure you meet the criteria needed to get coverage, and to see if there are any specific brands that are covered. If you are at all unsure of how your pump is covered, call your insurance company to ask for clarification.
Differences with patch insulin pumps
Patch pumps (such as the Omnipod®) that are disposable may be covered under either your insurance plan’s pharmacy benefit or its durable medical equipment benefit. Since coverage for these benefit categories may differ, make sure you review your plan documents to understand coverage criteria and your associated costs.
Insulin pump supplies
Coverage and costs can vary for supplies (reservoirs and infusion sets) included in your plan. Many plans allow you to order from the manufacturer, but not all do. These details can be found under either the durable medical equipment section or the pharmacy benefit in your plan policy document.
The company that makes your insulin pump may also be able to help you navigate any insurance difficulties you encounter. Calling the main customer service number (usually printed on the back of the insulin pump) can connect you with a person that is familiar with your account and insurance provider. See Help with Your Diabetes Prescription and Insulin Costs for more information.
Continuous Glucose Monitor (CGM) issues
Requirement to align with plan criteria
Similar to insulin pumps, if you are not currently using a CGM but want it to be covered, you may need to meet certain criteria. This could include a prior authorization or precertification. When you make a request, it is helpful to include evidence of medical necessity for a CGM. Highlighting frequency of testing or meeting certain HbA1c levels may help your request be successful. See Section 2 for more information
CGM Supplies
Coverage and costs can vary for CGMs and associated sensors included in your insurance plan. Many plans allow you to order from the manufacturer or distributor, but not all do. These details can be found under either the durable medical equipment section or the pharmacy benefit in your plan policy document.
Check to see if your plan covers a CGM, and review the criteria you will need to meet to get that coverage. Also, see if you can determine any costs you will be responsible for paying. Please see the sample appeals and exceptions letter provided in later sections of this guide. If you are applying for a prior authorization, there are usually standard forms from your health insurance company you will need to complete.
The company that makes your CGM may also be able to help you navigate any insurance difficulties you encounter. Calling the main customer service number can connect you with a person that is familiar with your account and insurance provider. See Help with Your Diabetes Prescription and Insulin Costs for more information.
I never realized that every insurance company and every plan is very different. Their contracts really determine a lot of what they cover, especially when it comes to a specific device or treatment. I reached out to the manufacturer and was able to get access by working with them directly.”
One last important note
If you experience challenges in gaining access to your preferred treatment or device, it may be a result of the agreements and contracts that your health insurance plan has with specific manufacturers. Each insurance company contracts with certain manufacturers, and these contracts can have broad influence on what you can access. It can affect your medication’s formulary tier placement, the price paid by the plan, your costs or the specific brand covered. Therefore, you may get a denial of coverage for your treatment.
If you learn your denial is specific to your particular brand of insulin pump, CGM, or insulin, while other brands are covered, this is likely due to a contracting arrangement. In this case, you can request an exception that will require your plan to cover your preferred option.
