With all the recent events surrounding medical care/insurance in the US, including the negative coverage of claims’ denials by healthcare insurance companies, I am interested to hear if/how people on this forum are affected by this issue as it relates to their supplies, treatment and care of Diabetes.
I know very few diabetics so have no knowledge other than my own. I am on Medicare and have Tricare as secondary insurance so I am very fortunate to have excellent coverage at this time.
It’s going to be interesting to see how things shake out coverage - wise over the next year or so. I have Employer sponsored coverage at the moment but the annual enrollment is coming up in July. We always have a change under the guise of better coverage but it never is. Then again I shouldn’t really complain as I am lucky enough to actually have coverage.
I’m a T1D on BCBS Federal Employee Plan. It has been great in the past but I’m starting to run into issues. I’ve been on Rybelsus for over a year to help with (a lack of) insulin sensitivity among other things. It helped me get to my lowest A1C ever. But this year my insurance is requiring a prior authorization for it, and they won’t accept anything my doc says because I don’t meet their criteria (not type 2). I’ve never not been able to get a med I’ve needed and my doc has requested before. I’ve tried appealing, but they make it very slow and the paperwork seems to be disappearing and/or stalling out. Meanwhile my A1C (and weight) are creeping back up…
@bwschulz just my 2 cents, but try to find the Utilization Management Guidelines for your plan. You will have to dig for them, because your insurance company doesn’t want you to find them. It’s what they base every coverage decision on, for every drug denial, for every procedure denial, even for cgm or pump denials. They have a step by step methodology of who is approved and who isn’t. Maybe there is a point or 2 that does apply to you that if focused on by your Dr will get you approved on appeal. I have found the UMG to be a useful weapon against the insurance companies many times.
I’m 73 on Medicare A,B, C and D. Been on insulin and Dexcom for 3 years. Part B provides the CGM. Had to get new Part D this year as previous company no longer covered several drugs in formulary. Was prescribed an Omnipod 5 in Dec so waited for Jan to order with new plan as pumps are covered under Part D. It was a stressful nightmare finally getting approval. It required asking for help from the nurse educator who gave me area pump representative. He tracked down where the issues were (multiple). I initially received a one month supply and training prior to the problems. Spoke with pharmacy yesterday and they said they were mailing 3 month supply yesterday. Hope insurance didn’t block again. My point is ask for help when turned down. I jumped through all the hoops, was blatantly lied to. One agent asked if I had tried changing my diet and what other medication could I take? I explained if they could give me a new pancreas as mine was removed perhaps that might work. They must be paid to decline.