FUDiabetes

Changes, they are a comin' (Jan 2020)

Novo nordisk also makes tresiba which I prefer over levemir or lantus… lasts about 24 hours, not sure if he is on 1 or 2 shots per day, but tresiba would definitely be 1…my insurance company switched to levemir, but humalog instead of novo log…but tresiba and levemir were interchangeable…

2 Likes

I love that suggestion, and if possible, I’d appeal - especially with @Eric at your side! He really helped EH and I get the omnipod!

2 Likes

My insurance switched me from Contour to Accu-Check (and from Humalog to Novolog) last year. I was upset. But, for me, it ended up not being worth fighting.
The Accu-Chek Guide is a good meter. The Contour is, I believe, slightly more accurate, but the Accu-Chek is still among the top meters accuracy-wise. The Guide has a better port light than the Contour. (I found the one on the Contour a little dim and it had to be turned on whereas the Guide’s light always comes on.) Accu-Chek also has a more thoughtfully designed lancing device and test strip vial. (The strips don’t fall out if you drop it or tip it while taking out a strip.)
In your case, it might be worth battling insurance especially since you are fighting for your child rather than yourself. In my case, it wasn’t.
(You could hoard some Contour strips for when accuracy is of particular importance or for when you doubt the Accu-Chek and use Accu-Chek for everyday testing. I think you’ll find they are similar, with the Accu-Chek just tending to read a few points lower than the Contour)

1 Like

In my experience they have little interest in “practical” reasons reasons why people prefer a certain strip (eg it’s the most accurate—- they’ll just say that’s subjective and they all meet fda standards) but will consider ironclad functional reasons—- eg this meter has audio functions and the patient is blind. I’ve also read somewhere in my Caremark stuff that they have an exception to Provide freestyle strips for people using omnipod as that’s what the system calls for… though not sure if you’re still podding if you’re on the loop.

I was frustrated when Caremark switched me to accuchek guide because I don’t like change, particularly change I have no say in… but I’ve actually turned out to be quite pleased with it

3 Likes

Buy them on Amazon. They don’t cost much.

1 Like

Then Nano has apparently been discontinued. :frowning:

Here’s the email I’ve sent to our Endo office - we’ll see where it goes from here:

Laura,

We received the following letter from CVS (attached.) We would like to continue using our current meter (Contour Next One) so it appears that we need an authorization letter submitted for review and, hopefully, approval so that Liam can continue using the Contour Next One meter. The reasons we are requesting to keep this current meter are as follows:

  1. First and foremost, to help him be as independent as he wishes to be, the small size of the Contour Next One meter allows Liam (5 years old) to grip the meter with his small hands and check his own BG levels without aid from adults. We have attempted to utilize larger meters in the past and Liam has difficulty holding these and using them effectively. He has been using the Contour Next One meter and has become familiar with this meter and introducing a new, larger meter to him will most certainly cause frustration and create a situation where he no longer wants to be independent. We always promote independence even at his young age, for simple tasks that pose no threat to him (such as administering insulin.)

  2. The Contour Next One has been a very reliable meter for us as far as it’s accuracy is concerned. We realize that the Accu-Check meters are also accurate, but the accuracy combined with the small size of the Contour Next One meter makes it unmatched for someone as young as our son to maintain his own independence where he wishes to be independent at his age. Accu-Chek used to offer a small meter as well - the Accu-Chek Aviva Nano, but as you can see from the below screenshot (taken from the meters offered at the link within the letter under “What to do Next” section), that isn’t one of the meters that’s offered, and that model has been discontinued either way.

image

  1. The test strips for the Contour Next One - strip for strip - are cheaper in all instances than the Accu-Chek meter strips. See chart below. This data was compiled from the meter websites as well as Amazon for the cost of the test strips - 50 strips comparison cost.

Because all of the meters use the same size blood drop sample (.6), this is not a factor that we are taking into consideration.

Please advise as to how we should proceed in this regard. We really love our Contour Next One for our son and we hope we can get approved to continue using it so that he can take ownership of his diabetes in this simple regard. This really is critical for him eventually taking full ownership of his health over the long term. By allowing him a process that he can handle (ease of use, small enough that he can use it alone) early on, he will grow to be independent and take control of his disease.

4 Likes

Good luck with it! In my experience it will likely come down to how your plan is structured. If it’s a self funded plan with a contracted PBM (as is mine) it will end up on the desk of someone who actually works for the same organization to some extent as you do and they’ll likely approve it because it’s ultimately a reasonable request and the cost is likely negligibly different…(might require legwork on your own part to get it to their desk because the doctors office would have no idea how the dots connect).

If they’ve actually hired Caremark to control the purse strings entirely it may be a different story where some bean counter may just rubber stamp it NO because there’s a formulary alternative and that’s all they’re required to care about. Please keep us posted.

1 Like

That’s the UST400 and earlier PDMs, it’s not just FreeStyle, it is a very exact version of the FreeStyle test strip (not ‘lite’, whatever that word means.) Pretty much the pharmacies in the US can’t supply the relevant test strip any longer so they are only available on demand (and check what you are given) to podders who need them.

Ironically my experience with the Abbott product was that it consistently read low compared to the Contour Next One that I am using now (with the Omnipod). I guess that’s safe for Insulet and Abbott; they don’t get sued for raising our HbA1c, that would be our fault. That said, as of this moment I use so few test strips with the G6 that I would not hesitate to buy the Contour ones myself, if I had to.

There are two threads running in parallel here with respect to US insurance coverage; one is changing between Eli Lilley and Sanofi for analog insulins; Humalog <-> Novolog etc. I don’t have an issue with this, they are pretty much generics so far as I am concerned. The other is changing test strip manufacturers, I do have an issue with this. The accuracy of test strips is low and the accommodations the manufacturers make both to avoid being sued, or social media’d, and to fit the US requirements, mean that we have to learn the test strip. Changing is challenging and challenge is dangerous.

The nurse wrote back and said the following:

Prior Auth was attempted, however, since Contour Next strips are currently covered, the criteria is not met. We will need to submit the Prior Auth after January 1, 2020. The next fill date is Feb 19, 2020 since they were purchased Nov 19.

Please call the nurse line, after January & request a PA for the strips. You can refer the nurse that gets the call to my documentation, which has all the info there.

Does this sound about right?

Makes sense…

Indeed; it is, of course, terminally dumb and a total waste of everyone’s money, time and life, but it is right.

The insurance company is unable to process next years stuff until, well, next year. So if you need something like, say, insulin, on Jan 1, 2020 you can’t ask for it until, like, Jan 1, 2020. I, well mostly my wife, spent a very significant number of hours on the telephone to moda (our insurance company) on a broadly similar issue, eventually moda relented (my wife is like that.)

It is a bureaucracy in the manner of Kafka (a well know Austrian insurance adjuster, who worked in a very capitalist country): You can win, but it might kill you, or send you mad; your choice.

Those doom laden statements stated, channel the inner squirrel, buy it on Bezos (he paid no taxes, so he has more test strips to sell cheap), hang in there. It will get better.

1 Like

Depends on the agreement made between CVS and your insurance company or employer.

I had a similar experience occur with CVS with my Afrezza. My employer required that enrollees in my plan be given an opportunity to appeal before our open season ended - so that people would have the option to choose a different plan. It was written in the contract with the insurance company when formulary changes were approved. CVS could not process my PA appeal for Afrezza in the time defined by the contract, so I was given a one year override and Afrezza will still be covered for me for 2020.

However, that isn’t necessarily the standard. You could call your human resource department to see if there is any opportunity to appeal in advance, but it might be more trouble than it is worth. If you have to stick with the plan regardless of whether the PA is approved, then it probably isn’t worth the effort of attempting approval in advance.

This is what I currently do. The hassle of going through the appeals process is not worth it for me for test strips. With the G6, I do not need to test as often as I did with the G5 anyway.

The rebates on test strips especially bug me because my benefit is coinsurance based. Despite my coinsurance on test strips being only 20%, the amount I pay for “covered” test strips is not far off from what I pay out of pocket without insurance on amazon.

2 Likes

I agree…I’ve bought the majority of my test strips out of pocket over the years… fortunately I found a real cheap one that I liked… coincidentally since it’s relevant to the original topic—- I only stopped buying mine out of pocket on amazon when my Caremark plan switched to accu chek guide a year ago, because I’ve found them to be fine for my needs

3 Likes

I suspect a 5x markup is routine now. I pay $144.99 for 100 Contour Next One strips (from Walgreens), the price on Amazon seems to run in the range $33 to $36 (depending on quantity bought), so that’s slightly over a 4x markup and I suspect the insurance company actually pays less (after the ‘rebate’) than we do on Amazon.

All my running costs are all similarly inflated:

Omnipod Dash pods (1 month, Walgreens): $617.99
Dexcom G6 Sensors (1 month, Walmart): $416.41
Dexcom G6 Transmitter (3 months, Walmart): $295.21
Fiasp insulin vial (2x10ml for one month, Walmart): $653.37

So that’s $1786.17/month or $21,434.08/year ignoring the less frequently used items like test strips and doctors office visits. It means I have to come up with $5358.52 in the first three months of the year, plus about $4389 for the insurance (including my wife) for those months; almost $10,000 cash.

Of course after that point I’ve met my out-of-pocket max and I “only” need around $13,500 for the remainder of the year (including my wife’s insurance). I know precisely how must I will spend next year before my rebates (credit card and income tax reduction); excluding my wife’s insurance this time that’s $14,778.

That’s as cheap as I can make it; even if I assume I might be able to get the stuff above at 1/4 the price retail I would still pay $5358.52 over the whole year (as opposed to the first three months). I’d still need the insurance and I’m pretty sure I would end up paying more than $641.48 for other stuff, like the test strips and the Fiasp pens I have for emergencies, so I would pay more than I do with insurance.

I’ve also noticed that the suppliers, pharmacies and so on, try very hard to get insurance details; you have to lie to their face to get the retail prices. I’m guessing that is because pharmacies and hospitals all get a little cut from the ‘rebate’.

2 Likes

Here’s what just happened on the US political front:

So that comes after the US Congress lower chamber (the “House”) had advanced a bill with a provision that is actually much more important:

That bill would have freed up the executive branch of the US government to negotiate drug prices; something that happens everywhere in the world that has functioning healthcare. The explanation is in the fifth paragraph of the CNBC article, quoted in full here:

Current rules prohibit the Department of Health and Human Services from negotiating drug prices on behalf of Medicare — the federal government’s health insurance plan for the elderly. Private insurers use pharmacy benefit managers to negotiate drug rebates from pharmaceutical manufacturers in exchange for better coverage.

The weird drug price markup followed by the kickback which I described above (inflate the price five times then get a kickback of 4/5 of that) is to a large extent motivated by the fact that doing this causes the central government to have to pay the 5x price. So Medicare recipients see the 5x price and either the patient or the government pay that price, maintaining very large profits for everyone else.

The Wyden/Grassley bipartisan law described in the first link would partially scupper this trick; by forcing an out-of-pocket maximum for Medicare recipients it makes Medicare look a bit more like the insurance plans required for the rest of us and it potentially limits the extra profit to 4/5 of the out-of-pocket maximum, so Medicare Part D insurers would be in the same boat as regular insurers. That’s a lot of money.

2 Likes

@ClaudnDaye I’m sure you have resolved the Prior Auth issue by now, but I ran across the Optum RX Prior Auth form the Drs have to submit for patients. Might help for the future if you need to tailor challenges for denial of service.

OptumRx Prior Auth form

1 Like