FUDiabetes

2021 formulary surprises?

Anyone have any major formulary changes for 2021? Usually by now I get a letter in the mail from Caremark telling me what the new year has in store for me… this year no letter but I happened to look at their formulary and saw that accu check guide strips have been removed and one-touch is back on… which is a bit of a bummer because the guide strips worked well and one touch leave a lot to be desired for me… but whatever life will go on.

Also of note I still see omnipod and omnipod dash and dexcom on the 2021 formulary for Caremark but when I look it up actually logged into my own portal it’s not available through my sub-plan… which just means I’d have to go through supplier instead of pharmacy still… which was a bit of a disappointment since I’d sent a couple emails to our plan administrator asking them to fight for those two things in our pharmacy benefits when they renegotiate with Caremark—- I don’t know if that’s happened yet— or if it’s every year or not but hopefully someday my efforts will bear fruit.

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Our company just went through a buyout. Previously we had a variety of health plan choices from both Regional and National Insurers; now we have one, UHC. I won’t lie, I’m kind of nervous about the change. On the bright side I will get to keep my care team, and the National formulary if it applies to our sub-plan might actually be advantageous for me. My insulin moves from a Tier 2 to a Tier 1, and it appears that Dexcom is a formulary item now at a Tier 3 coverage (more $$ to acquire than my DME cost, but conceivably less hassle to obtain). Contour Next strips are Tier 2, One Touch Tier 1 (no surprise there), and all others are exempted. Time will tell if this is a positive change or not as our new plan takes effect 1 Jan 21.

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At least it seems that the dark ages of UHC only pushing one brand of pump are gone. Hopefully they continue to do things that are in the best interest of their patients.

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I don’t think any insurance mega corporation is interested in doing what’s best for its customers unless it’s also what’s best for the bottom line… it think the burden falls on the pump makers fo fight hard to make their products competitive to get them covered

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I received a letter from BCBS that their formulary changed and the regular omni pod is no longer covered, but omni pod dash is.

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Do you know much about the differences? When I spoke to omnipod last year they basically indicated there’s not much difference but they’re marketing the dash more toward pharmacy

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@Sam No, I don’t know too much about the differences except to say the, the older version you can use with Loop, which I haven’t tried yet and there is no glucometer. I’m going to miss the glucometer.

I talked with my pharmacy (Sam’s) and they checked, Dash is covered under the pharmacy benefit for me and they can supply it. I’m thinking too, getting it as a pharmacy benefit, I won’t have to stay with omnipod for two or four years, which will be nice not to be locked into a specific pump for so long.

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Yes at first glance I would be more interested in procuring it through a pharmacy benefit actually I think I would be willing to give it a try if it was through pharmacy but not very interested if through a supplier just due to the headaches involved

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I get the regular Omnipod as DME but direct from Insulet. They are a trouble free supplier, have not had any snafus. Insulet handled the prior auth etc with insurer. It’s easy to set it all up on their website.

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It’s only easy if they’re contracted directly with your insurer…

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@Sam. Per Omnipod, the The difference between the traditional omnipod and the new dash system is:

What are the main differences between the new Omnipod DASH™ System and the current Omnipod® System?

The Omnipod DASH™ PDM has a modern, touch-screen interface that is lightweight, simple, colourful and intuitive.

The design of the new interface has been led by user-experience to optimise navigation and displays.

The Omnipod DASH™ System features connectivity using Bluetooth® wireless technology.

The Omnipod DASH™ PDM is smartphone-like technology where Users can easily enter manual BG readings from any BGM they chose to use.

There are some added features (such as being able to program a zero basal rate, set fractional insulin to carb ratios and track Pod site-locations) with the new Omnipod DASH™ System.

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I didn’t get the usual letter from Caremark, either…but this reminds me I need to double check our new insurance benefits; switched from UHC to Aetna (still with Caremark for pharmacy).

Do you get dexcom supplies covered under DME? I never won the battle of trying to get either insurance (UHC or Caremark) to cover it, so I’ve been paying for the Libre out of pocket.

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Yes they’ve always covered mine I guess under dme through equipment suppliers…

I think if you have a t1 diagnosis code it’s a standard of care thing… I’d discuss with your doc why they’re denying it and if it’s related to coding

Did you call dexcom directly ? Usually they line you out with who the supplier is that works with your insurance…

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I know my doctor tried to get it covered based on a trial run I did with a CGM that showed I was having lows (they weren’t all true lows, which she knew, but she wasn’t going to mention that…). I spent 6 months back in 2018 going back and forth between calls with doctor’s office, Dexcom, DME suppliers, and Caremark…UHC said it was covered by pharmacy, Caremark said covered by DME, both Dexcom and DME suppliers almost managed to get things looking like they were going through but something always came up in the end and coverage was denied. I just gave up after a while. I’m ready to try again this year, even if I “only” manage to get the Libre sensors covered. I don’t have a lot of lows and never overnight, so I’m not overly concerned about the lack of alarms (yet).

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This can be the confusing part is that it is likely only covered by ~certain~ dme suppliers that are contracted with your plan for that specific supply—- so unless one has specifically told you “yes we are contracted to ship that particular item to you with your insurance but we aren’t going to do it because you don’t qualify based on______”then it sounds like possibly you just haven’t found a contracted supplier ? It can be a pita… several of the ones dexcom told me I could use weren’t actually contracted with my insurance… I’d find out “oh no we are contracted for breast pumps with your plan not diabetes monitoring supplies” after spending a week investigating it—- or often you’d call and go through the whole setup and they’d just never call back if it was a dead end… then weeks later you’d spend 2 hours on hold to find out something like that

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@Pianoplayer7008

If your insurance contracts with Fifty 50 (a 3rd party supplier here in Texas) I’m here to let you know they have been great to deal with for both my pump (Omnipod Eros) and Dexcom G6 supplies. I’ve received all shipments from them within 2 days of placing my orders. A plus, the contact I work with is local (15 mins away).

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If Caremark is your plans PBM, they usually have a website or online search tool, specific to your plan. I would trust that over a call with Caremark.

That’s how I found out mid year 2020 that as of 2020 Dexcom G6 could be covered by either. I switched to Pharmacy, which was lower cost, but allowed only 30 day fills. Costco auto-fills and I get automated call when time to pick up. Lower cost and predictable fills. Costco will auto renew RX with doctor electronically.

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The dash is an Android Phone minus the SIM card. The Horizon, due out early this year, will work with any Android phone.

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I think I did check with one of the suppliers and they said they were, but who knows. It was a mess.

Ohhhh, thank you, I will check!

I would prefer that…I hate phone conversations (with anyone). :laughing:

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