FUDiabetes

Prior authorization Novolog - magic words

Due to my current crappy insurance, I have a new doctor, and need prior authorization for Novolog pen fills capable of half units.

What are the magic words that the doctor should use ? I did try the other short term insulins and they don’t work for me. There are no half units either.

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I would try “documented poor treatment efficacy with formulary alternatives”

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Thanks.

I’ll try that.

Has anyone else had experience with other effective magic phrases?

Does the words also work for test strips? How many test strips do you go through in a day? My bad insurance will now only cover 4 strips, previously, the prior authorization provided 6, which was adequate. I don’t use CGM. The Dexcom drifted too much for me. I also felt that it made me feel “too connected” if that makes sense.

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Makes perfect sense… I don’t like that either and I don’t like that I feel psychologically dependent on it when I use it…

I don’t know what the magic words are for test strips… I suspect your doc probably knows all the tricks… and these days there’s over the counter options that are likely not more expensive than copay alone for “insurance strips”

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My insurance allows 4 test strips a day too, and that’s not enough for me even with CGM. I buy extra via Amazon and they are about the same price as my test strip co-pays.

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Depending on what you are trying to get - insurance for a 1/2 unit pen versus a whole unit pen should not be a very hard thing to get. I think the pens cost about the same, so it should not matter to the insurance company, the cost is roughly the same. This should not be a difficult one to win.

If you need a 1/2 unit pen, you need to specify that you need more granularity in your dosing. State that whole units do not give you enough adjustability, and 1/2 unit dosing provides more scalablity and precision. State that you are unable to fine-tune your dosing with whole units. Not being able to scale in 1/2 units increases your risk of both hypoglycemia and hyperglycemia, and increases the risk of complications.

So for 1/2 unit pens, lets say the “magic words” are:

  • granularity
  • adjustability
  • scalablity
  • precision
  • fine-tune
  • hypoglycemia
  • hyperglycemia
  • increased risk of complications

++++++++++++

A few more points. The NovoLog Echo pen (NovoPen Echo, is I think what they call it) has the memory function as well as the 1/2 unit dosing. The memory lets you know the time of the last dose, which can help you calculate your IOB, etc. So I think that would be a good thing to mention.

Furthermore, the Echo pen has replaceable cartridges, so the cost might actually be very comparable.

Here is a quick guide:

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The “price” is approximately the same… however the negotiated rebate is secret and could be very different… like none at all with one mfg and 95% with another… hence the whole problem with prescription meds in the USA

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Yes, I agree with that. But as you said, that would generally be when going from one manufacturer to a different one, like Lilly (Humalog) vs Novo Nordisk (NovoLog).

Since @lh378 is currently on NovoLog (I think), I suspect switching from a whole unit NovoLog pen to a 1/2 unit NovoLog pen would be an easier switch, than if she were to go from a Humalog pen to a NovoLog pen.

I would hope so, anyway.

But agreed, who knows what games they are playing with the pricing.

Maybe… although who knows… maybe they say “here’s the discount package we’ll offer on this list of products” and some items are in it and some not. The outrage is that with the current system we can never know…

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Let me clarify:
I’ve been using the 1/2 unit pen and the refill cartridges. I have a new doctor who doesn’t seem to know the correct words and phrases to use. The prescription has not been filled. The previous doctor, part of the same practice as the current one, seemed to know the “right words”. I asked the new doctor if he can just use the same words.

It’s been frustrating. I have one to two bottles of Novolog that I can refill the cartridges using the methods recommended for now.

Argh!!

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Last few years I’ve been getting a copy of the insurers medical policy for whatever it is I am trying to get approved ( for example cgm policy, pump policy etc.). Those medical policies usually spell out the magic words that are needed for approval. If you call the insurer they will send it to you.

Not sure though if your insurer will have a policy for your need, might be a formulary issue. Do you have a copy or online access to the formulary list? If something is not listed it can still be approved using the magic words noted above.

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@lh378. The best place I have found for the magic words are on the insurer’s Utilization Management Guidelines. Use their printed guidelines to tailor your ask. Most insurers have these guidelines posted on the web if you search for them. For the few that don’t, just call the insurer’s and ask for a copy.

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Now I feel stupid. What is drug tier 1, 2, 3 on the formulary list? On my insurance comprehensive drug list, the following does not require PA. They are listed as tier 2 drug. Doesn’t that mean that PA is not required?

NOVOLOG INJ 100/ML 2
NOVOLOG INJ FLEXPEN 2
NOVOLOG INJ PENFILL 2

I searched in the formbulary and Fiasp appears to be coverd (just like the 3 Novologs listed above) Have any of you used Fiasp?

I’ve been using Fiasp since it first came out…and like it a lot. For me it’s got a quicker start and a shorter tail compared to Humalog. Fiasp works great for correcting a high especially if you catch it early while BG is rising. But I’ve never tried any other rapid insulins besides those two.

Those tiers sound like your doc should be able to prescribe what you’re looking for. When my pharmacy has “ trouble with the insurance” ( their words) I call the Pharmacy Services dept at my insurance company to work things through. You might have to do that to figure out where the glitch is with that prescription.

Yeah that means that a PA shouldn’t be required. Somewhere in your benefits description you should be able to find a description of the tiers and how each tier is paid differently… frequently all brand name drugs are on at least tier 2 and generics on tier 1. So they’ll have a different formula for the different tiers… Eg maybe “$10 copay for tier 1 drugs 90 day supply.” Tier 2 “25% coinsursnce 30 day supply” just for a made up example

I’m wondering if your doc is just ordering the wrong ones out of habit because not many people use penfill… if that’s the case sometimes it can be helpful to actually take your old prescription label to your pharmacy and ask them to submit a refill request to your doctors office… or if you’re using mail order you may have the option with their online portal to have them send the exact rx request you’re looking for to your docs office…

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For most Insurers with a pharmacy benefit utilizing a 4, 5 or 6 tier formulary:

Tier 1 is a generic formulary preferred drug and the lowest cost copay (e.g. $15/Rx)
Tier 2 is a brand name formulary preferred drug with a higher cost copay (e.g. $55/Rx)
Tier 3 is a brand name formulary NON-preferred drug with a higher yet cost copay. (e.g.$90/Rx)

Most pharmacy formulary plans allow for a 90 Rx on prescriptions that are taken regularly long term such as insulin, or heart drugs or cholesterol drugs. Generally the cost for a 90 day Rx is twice the 30 day Rx cost.

If the formulary does not specify ST, QL, or PA next to the drug, you usually don’t need a Prior Auth.

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Sorry I am late, I just saw this.

Agreeing with Sam and Elver, it is covered, but the higher tiers will just cost a little more.

That’s a great idea @Sam.
I spoke with the insurance company, and was told that the generic is admelog. They want me to use admelog before they allow the Novolog. How insane is that? I inquired why is the Novolog listed as PA not required if they insist that I use the generic? The insurance company could not explain except repeat the same statement. Has anyone else experienced this?

Hmm… I’d just dig into the details of the Plan to see if that’s actually right… or just try to get the rx filled for novolog and see if they actually refuse it. That description doesn’t match my experiences… usually other formulary just cost more and are less incentivized

Outwardly, the decision is based on profit margin for the pbm\insurer. Additionally, some pbm’s won’t cover generic Humalog because there isn’t enough profit to cover all the kickback\rebate schemes in place.

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