Quantity limits on Diabetic Supplies

SarahKelly · #1 06-01-2010, 06:10 PM

Anybody else's Rx or insurance company try to limit their amt of insulin, test supplies or glucometers? We just got a letter about this and I'm rather frustrated. I spent hours on the phone today and got nowhere. From that time I found I need to appeal each and every RX individually and then wait to see what they decide.
Does this seem wrong to anybody else?

liasmommy2000 · #2 06-01-2010, 06:14 PM

Yes, they can do that. For us the issue was test strips. Once we found the magic way for the endo's office to write the script so that the DME supplier would even SUBMIT it to the insurance along with a letter of medical necessity from the endo we had no problems. Literally once those things were submitted we had an approval within hours.

Good luck, it was still an extremely frustrating process, though for us it was all due to the horrible DME supplier we used (and soon dumped).

sarahspins · #3 06-01-2010, 06:16 PM

I've never had issues with amount of insulin, past dealing with one really stupid person at Walgreens who questioned how much I "needed".. it was actually my insurance who fixed that one for me.. they've never denied any amount. While I was using Apidra they did keep sending me letters encouraging me to switch to something with a cheaper co-pay.

My insurance does limit test strips.. I am only "allowed" 300 a month.. but that works out to every 24 days.

I've never gotten a glucometer with an RX, so I can't help you there.. apart from the Aviva I bought recently when my lancing thing broke (I bought the meter to get the multiclix) I haven't even bought one retail in probably 8 years.

SarahKelly · #4 06-01-2010, 07:03 PM

Laurie-what was the magic wording? Any ideas are much appreciated as this is difficult for me in terms of not just getting angry.

Seans Mom · #5 06-01-2010, 07:52 PM

I'm not sure of the "magic" way but I've read before and I know our endo office words the strip rx as tests per day, not how many strips per month.
Ours is written as test 12 times per day.
Although we've never been told we have a limit with our insurance so don't know that it makes a difference in our case, but others have posted before that it made the difference with their insurance covering more strips.

Also with insulin it is written as how many units per day, i.e. 40u per day. In our case Sean uses 20u or less per day(typically ~12u but some days he just needs more from eating or illness, etc..) but by putting twice that amt. we have an ample supply for corrections, cartridge filling, priming, bad sites, etc...

PatriciaMidwest · #6 06-01-2010, 08:14 PM

What did the letter say? This kind of stuff is so frustrating.

We get 300 strips a month without much hassle. Not sure what would happen if we went over that. I also order as soon as it shows as refillable (21 or 24 days?) so I have a little buffer there.

Insulin is a bit tougher. I've had PRN RX rejected. The pharm/insurance company wants to see a Total Daily Dose and then double check the number of vials. Make sure your doc adds extra to the TDD for changing tubing and resevoirs. etc. Our back up insulin was rejected several times (Apidra pens) and I gave up trying to fight it but then someone at the insurance company actually put in a override and now it is covered for one year.

Keep at it! Maybe if you post your insurance plan someone can give you some specifics in dealing with them.

hdm42 · #7 06-01-2010, 10:10 PM

Oh yeah!

We changed insurance in January, and it has been a nightmare. The first month, they rejected all his D scripts as being over their "standard limits". The endo's office spent a week going back and forth with them to get the overrides. Then it happened again in February, another set of phone calls between endo and insurance. Only half were rejected in March, which I dumped on the company HR person and only 1 rejected in April, which I again dumped on the company HR person. Last month they all went through, so I'm keeping our fingers crossed that they've finally gotten it all straightened out.

Our doc had to write orders for tdd units too, but they included priming & some extra in there to get us the amount they wanted us to have. Same thing on test strips & lancets & needles.

It's ridiculous that insurance beauracrats think they know better than the doctor what we or our children need.

SarahKelly · #8 06-01-2010, 10:51 PM

Isaacs script is written as 12-15x's per day plus additional checks if ill, if blood sugar is high check every two hours, if blood sugar is low check every 15 minutes until BG is above 100. This has allowed us a cushion, but it makes it so that I am not thinking twice about when/why to test. The letter stated that only 200/30 day supply for test strips. I just can't imagine. And I got no help when I called. It just seems like there are so many areas of difficulty with treatment of t1d.

PatriciaMidwest · #9 06-02-2010, 12:28 AM

Sarah --

I think the "additional tests as needed" part is what the insurance companies don't like. They may want a hard number to work with from your endo, although they never tell us up front how to get claims paid for do they?

Have the endo write a letter of medical necessity and RX with a specific number of strips needed per day or month and hopefully that will override their 200 strips a month limit.

Good luck.

carcha · #10 06-02-2010, 07:08 AM

My insurance is great about strips, but they are so stingy when it comes to insulin. I can't tell you how many prescriptions my very patient doctor has written, but I still do not ever have a spare vial of Humalog in the house. (Have six vials of NPH in the fridge at the moment, however - go figure!) The problem seems to be about the insulin expiring after 30 days - this is what we were told at diagnosis, but the insurance company does not acknowledge this. So, given our current TDD, they feel a bottle of Humalog should last us around 50 days. The nurse told us to toss it after a month. So....more phone calls to make. Sigh.