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WARNING-2014 Prescription Exclusion List for ALL Express Scripts Subscribers

Discussion in 'Parents of Children with Type 1' started by moco89, Nov 1, 2013.

  1. moco89

    moco89 Approved members

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    I came across this and I thought that a heads-up might be useful.

    This applies for all Express Scripts members, regardless of plan.

    Excluded diabetes-related items, that are not covered, include:

    Insulin: Apidra, NovoLog

    Test Strips: Abbott (Freestyle, Precision), Bayer (Breeze, Contour), Nipro (TRUEtrack,TRUEtest), Roche (Accu-Chek)


    https://member.express-scripts.com/images/pdf/2014prefdrugexclusionlist.pdf
     
  2. MomofSweetOne

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    What happens if one is allergic or doesn't do as well on one type of insulin when there is only one option covered? I know they said that they're in alignment with HHS guidelines to only offer one choice, but what happens when that one product doesn't work for the individual? We're having to switch meters, but I'm thankful at this time we don't have to switch insulin.
     
  3. mmgirls

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    But we have to be able to get an override from our DR. , Right?

    Not giving up Apidra and Freestyle for the POD
     
  4. Sarah Maddie's Mom

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  5. Beach bum

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    I'd make sure you have a ample supply just in case they give you a run around. I'd contact them ASAP in the event you are going to have to jump through hoops to get them to approve an override.

    Does anyone else find it ironic that the ad to the right of their page is "Who's the Boss?" Talk about sending a message?Who's the Boss? We are!
     
  6. moco89

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    Actually, because the prescription is not covered--at all--you will have to go all out and do an appeal. Unfortunately, I have appealed before with Express Scripts, and they are AWFUL.

    I recommend stocking up in 2013 so that you have adequate supplies for the time required for the appeal. You will need a month's supply, best-case scenario, if you are not using mail-order.

    When the prescription is denied at the pharmacy (you have to go and "try" to fill it in order to get "recognized" by the system), both you and your doctor will get a denial in the mail, and most likely a set of forms in order to appeal, but this just depends on whether their "system" is programmed to generate the appeal forms, for that particular prescription. Regardless of whether this is attached in the denial or not, you need to call Express Scripts immediately after trying to fill the prescription in order for them to generate an "appeal package" for that particular prescription, which includes a KEY paper detailing the prescription and the dosage (it's required for the appeal), or you could be waiting for a REALLY long time for their stupid papers. The customer service rep will ask you for the medication/prescription name and the dosage when you ask for the appeal papers, and MOST of them will not talk to you/deal with you without this information. You should make a copy of the prescription before dealing with Express Scripts over the phone for this reason. In addition, you have to use their appeal forms, or they will toss your appeal in the trash. Any documents from Express Scripts can take up to 10 days (not business days) to be received in the mail. There is no way whatsoever to generate the "appeal papers" electronically, even though they have all sorts of electronic portals and apps. Obviously, this is BS and they make money off of making you wait and deal with their crappy customer service, because appealing is very frustrating. In addition, when they mail the appeal pack, they often mess up the doctor's address, or the doctor's office cannot find the mail saying that the Rx was denied.

    You or your doctor can initiate the appeal, as both of you will receive an "appeal package" (that you should request by calling Express Scripts). I suggest that you initiate the appeal, write an appeal letter, and have your child's doctor write a letter. Attach the doctor's letter with YOUR appeal, and specifically mention the letter immediately in your appeal letter, so that it does not get "overlooked", and mention it as an enclosed item at the bottom of the appeal letter.

    Tell them not to mess the recommendations of your child's medical doctor, and that the individual reviewing your case (appeal) needs to have comparable credentials as your child's doctor (as in a licensed pediatric endocrinologist), and if otherwise, further denial is not-credible. Make sure to state that pre-determined policies written by administrators, corparate decisions and policies, and automatically generated denial statements are unacceptable for your child's individual case.

    Express Scripts responds to appeals in 15 days, after receiving the appeal. Make sure to send your appeal certified mail, return receipt. (You actually do have the option of an "expedited appeal"--intended for true, genuine emergencies, which results in a decision (I think) in 24 hours, but this is a REALLY BAD IDEA. You only get one chance to appeal, and if the appeal is denied, it is over. Don't do it over test strips and insulin!)

    Once you are approved, you will get a really vague recorded phone call or a message on your answering machine saying that the medication was approved, and as a chronically ill person, you would wonder who sent this message, if you did not realize that you recently filed an appeal. After this, you can typically get the medication filled at the pharmacy. Sometimes, the prescription will still get denied and you will have to call customer service who will tell you to get the pharmacist to do some sort of an override authorization (I forget what it is called-I have never had to do this, but I asked).

    Sorry for the poor writing. I hope that this was useful and informative.
     
    Last edited: Nov 1, 2013
  7. caspi

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    I just tried to call Express Scripts and the recording said there was a "longer than normal waiting time" (imagine that :rolleyes:) so I hung up. I called the pharmacy and they said we will have to wait until January to see if it is denied or not. Luckily this is where stocking up on our test strips comes in handy.

    We use the Freestyle strips with the Pod and I am wondering, since Express Scripts is the largest pharmacy in the United States, what this will mean for Omnipod if their customers can't get the strips. :confused:

    Guess we'll just have to wait and see. Moco89, thank you for the information. :cwds:
     
  8. MomofSweetOne

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    You'll have to carry an external meter; the pod still works after all. The same thing could be said about all the pumps with linked meters: Animas, Medtronic, Accu-chek. I don't think they're going to grant an appeal, but I could be wrong.
     
  9. caspi

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    I realize that and it's not the end of the world, however when you are paying for a pump that uses one type of test strip and then the largest pharmacy provider stops allowing that test strip, it's not good for that pump company.
     
  10. MomofSweetOne

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    Oh, it's very frustrating. I've wondered the same about the Accu-chek pump as my daughter had it on the top of her list to trial since she (we) have had such positive experiences with Roche customer service, unlike Express Scripts. We're not happy about giving up her Aviva meters at all, and there were tears about the larger blood sample required until we finally learned Verio IQ is covered.
     
    Last edited: Nov 1, 2013
  11. moco89

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    Your best arguments are going to be accuracy and the need to keep your diabetes data integrated (typically important with certain children using pumps). There are peer-reviewed research publications that evaluate the accuracy of the glucose meters by meter. OneTouch brand meters, were some of the worst-performing meters in a major research paper that I have. The only major brand that performs worse than OneTouch/Lifescan is Bayer brand meters. I have attached all sorts of documentation with my appeals, including peer-reviewed journals, of merely case reports, and I have been successful.

    I have access to peer-reviewed journals as I am a student, but asking your doctor to retrieve publications about meter accuracy, to aid in your appeal, should suffice. "Asking around" could get you the publications you need to aid in your appeals.

    How to file insurance appeals. (Advocacy for Patients, Inc. / Jennifer Jaff Center)

    * Nationally, although 94% of insurance denials are never appealed, approximately 70% of health insurance appeals are granted. (Referenced from Advocacy for Patients, Inc., now called the Jennifer Jaff Center--truly a phenomenal organization.)

    You just have to decide if this is worth the grief and frustration.

    FYI, this book (which I have) provides phenomenal information about doing insurance appeals. The book is actually a fundraiser for this organization.
     
    Last edited: Nov 1, 2013
  12. Beach bum

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    Kind of defeats the whole purpose of creating a paired meter and marketing it to the public. I wonder what the pump companies position is on this???

    I'm waiting with my breath held to see if our insurance company is revamping what is and isn't covered.
    I'd have to say if our insurance said that they don't cover OT strips anymore, I'd push for getting the T-Slim.
     
  13. moco89

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    People should get the JDRF in on this one.

    I don't know how on earth an "artificial pancreas" is going to be approved, in the first place, when we cannot even use meters that work with our pumps. An integrated meter would prevent all sorts of issues with the "artificial pancreas", too.
     
    Last edited: Nov 1, 2013
  14. MomofSweetOne

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    I wonder how the other meter companies and insulin companies are going to react to this. I've tried communicating with Accu-chek over how much we would like to continue to use their strips, but their response was to send me another co-pay card with a cap of $50 payment. That $50 per month is a drop in the bucket compared to the cost of their strips. I wonder if they'll start dropping their strip price to be competitive with One Touch or whether this will put some of the companies out of business. This is an area, too, that the difference between T1 and T2 becomes apparent. The $50 copay card would maybe suffice if my daughter tested only a couple times per day, but at the rate we go through strips, we need the coverage.

    Does anyone know what brands Medicaid covers? With him saying offering only one choice is according to HHS guidelines, is Medicaid now only covering one option as well?
     
  15. Jordansmom

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    Thanks for the valuable info Moco89. Can you imagine how overwhelmed their appeals process department is going to be Jan. 1 though? It could take FOREVER to get the initial paperwork, let alone a decision. They cannot be used to a massive flood of appeals all in Jan. This is going to be a disaster.

    I'm really upset about the possibility of losing Apidra. Honestly my DD could hurt herself. She's just starting to manage things alone and she does not have a clue how to dose insulin with the long DIA and tail of Humalog. Her DIA with Apidra is 3 hrs (with no tail). On Novolog it was nearly 5 hours. I've taught her she can be pretty aggressive with corrections with Apidra.

    I'm not giving up without a fight. I've already emailed Sanofi Aventis and Express Scripts. Not they that have responded. :mad: Sanofi does have some responsibility in this. They raised insulin prices this year significantly and released a statement saying basically that they did it because they knew they could make bigger profits off people with diabetes and no one could stop them.

    I think I'll contact my endo's office and see if they can start preparing an appeal response now. I expect they may get overwhelmed by requests come Jan. as well. Edited to add: I'll appeal, but I don't expect it to make any difference in this case.
     
    Last edited: Nov 1, 2013
  16. Jordansmom

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    We should all be pushing JDRF and the American Diabetes Association to bring all their political weight to bear. It doesn't matter what insurance coverage you have or what strip or insulin you use. Its about any insurance having the ability to take away our choices. Big policy changes like this always start somewhere. And when one company gets away with it and increases profit, they all follow.
     
  17. MomofSweetOne

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    Yes. We don't want to end up with only one inaccurate option worse than One Touch like New Zealand now has.:eek:
     
  18. moco89

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    Another thing is that the American Diabetes Association has been advocating for "test strip accuracy", so there is really some weight to having choice in meters.

    I can tell you that OneTouch has nothing to show for in meter accuracy, based on peer-reviewed journal articles evaluating meter accuracy.
     
  19. MomofSweetOne

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    How does the Verio compare to the One Touch Blue (and other meters) in accuracy? I haven't been able to find studies.
     
  20. Megnyc

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    Just fyi, the onetouch verio iq meter is great. In my opinion it is equal to or superior than all of the other meters on the market. I believe that there has been at least one independent study that showed it to be one of the most accurate meters available in the US. I'll try to dig it up later and post it.

    I'm still angry with express scripts though. We will be battling it out with them over apidra and flovent :rolleyes: (and they still keep sending me dexcom transmitters instead of sensors--- just utter incompetence)
     

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