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Cigna says "no" to insulin script

Discussion in 'Insurance Issues' started by jacobsmom, Feb 10, 2013.

  1. jacobsmom

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    My son is 8 years old, dx'ed at 3. Since diagnosis we have been through 3 insurance companies and I had never had the problem I am having now.

    Husband's company switched to Cigna insurance the first of the year. Our first issue came when our medical supply rep called me and said Cigna only considered Accu-Check their preferred brand of test strips and therefore, would not cover his Bayer test strips. I called and explained that my son is on a Medtronic pump and uses the Bayer Contour Link meter that reads to his pump. She said she could do an override, but we had to pay for premium prescriptions (5 times the cost). I said it was criminal but we did the override.

    Since Cigna waited almost a month to send me a prescription order form, I called and gave them the scripts over the phone to ensure we wouldn't run out. When I received the box on the 5th, I noticed it was missing insulin. Script was for 6 boxes--including one vial for school and one vial for overage or breakage. The only sent 4 vials.

    I called immediately and a Cigna pharmacist said that they received a prescription from the hospital for only 4 vials. I explained that we needed more than that and he also needed a vial for school. Pharmacist said call the doctor.

    When I called the doctor, the nurse checked and said she had a copy of the prescription saying he needed 6 vials. She called Cigna. When she called me back, she said they refused a vial for school and no vial for overage. The nurse looked back and said in November, he was using 43units per day and Cigna said that 4 vials were all that it would cover since that was 3,870 units per 90 days.

    When I looked at his current readings, he was using 47 units per day now. She looked at the logs and called Cigna again. This means we use the 5th vial, as he is currently using 4,230 units. The nurse said Cigna told her they refuse to send a 5th vial now, but Cigna said they would figure out how much he needs and how long it will last and will send a shipment early!!!

    I called Cigna and asked to speak with a Nurse Case Manager, citing previous phone calls from both myself and hospital that have gotten us no where. I got the run-around, sat on hold for 56 minutes. When the rep came back on she said they were "expediting" my request for a case manager and someone should call me on Monday.

    Has anyone else been getting the run-around from Cigna?
     
  2. caspi

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    We used to have Cigna and they were very stingy when it came to insulin. You got what you needed, nothing more. We dropped a vial of Lantus once and they wouldn't replace it - we had to pay out of pocket. Sorry you're going through this. :(
     
  3. swellman

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    We also get 4 vials and that actually covers 1 extra. We don't order every 3 months. We haven't had issues with Aetna and I think we just ordered 4 through United Health. The doctor doesn't actually say one is for breakage or the school but he writes it so we get 4 vials whatever that amount is per day. He wrote a new one for 50U per day which I think comes to to 5 vials in 90 days but I haven't submitted that. I can't honestly say I blame them for not wanting to cover extra insulin for "just in case" as it is expensive. I've always justified our overage since we don't horde it but order it when we need it.

    Are you sure you're using 47U per day? That seems like a LOT of insulin for an 8 year old.
     
  4. jacobsmom

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    Each prescription is a form from their office that states at the top, "This includes one vial for school and one for breakage," so even if it isn't written for "more" than what you need, that is assumed. They account for 20 units for pumping. Here is the issue: as you all know, insulin needs change day to day. Stress, hormones, the amount of food eaten, a bad site, changes in weather (hot to cold affecting blood and therefore, the amount of insulin needed) can all affect how much insulin is needed per day. Two months ago, Jacob used 4 less units per day, on average, than he does now, as an example. Over 90 days, that is 360 units.

    Cigna apparently uses the formula of counting every unit. By their formula, insulin needs do not change and so therefore, you receive the exact amount you are currently using for a 90 day supply, which is impossible to calculate, as it changes. In one month, you may use 2 units more per day or 5. None of those are calculated in.

    Their formula accounts that at 47units per day is 4,230 units for 90 days, giving us 5 vials. However, the next 90 order accounts there are 770 units left in the fifth vial from the previous order and therefore sends 4 vials for the next 90 days and so on.

    The issues with this: as stated above, insulin needs change, especially in a growing child. What may be "just enough" for one month, may not be for the next month. With our doctor, as in many places, there are thousands of patients and they cannot call each person's insurance company as insulin amounts change. So far, they have made 3 calls on our behalf. Secondly, for issues such as a bad site, there is insulin lost with any site change, with insulin that may had been used but is not working and the extra insulin used for priming the pump for a new site.

    There is also an issue of not having a vial for school. When our nurse contacted Cigna, they said they refuse a vial for school. When I asked what we were supposed to do for insulin for school, Cigna said "We don't care." In turn, Cigna does not care if an 8 year old boy dies because he doesn't have the insulin he needs. Any time you have a vial being taken back and forth with a child increases the risk of breakage, which Cigna also said they don't cover.

    This is not a case of "hoarding" insulin. This is a case of the what the doctor says is for the safety of an 8 year old boy. Yes, insulin is expensive. So is insurance and that is supposed to be what it is for. When the nurse called to change to 47units, which gives us the fifth vial, Cigna said the refuse to send it now but they will calculate how long 4 vials should last and send the next shipment early. When any insurance company steps in and says, over the pediatric endo, or any other doctor for that matter, what they will fill and what they won't, everyone should be worried.

    This is not Vicoden, this is insulin, something type 1's need to live. It is not a case of "should we give him insulin or shouldn't we." He has to have it or DIE.

    Since this issue has come up, I have done research on Cigna. Google them. There is a boy that needs a wheelchair that Cigna refuses. There was a story on ABC where they refused 2 young boys cancer treatment. A teen died after Cigna refused a liver transplant. There is currently a petition on Change.org of a young girl, whose 13-year-old brother has Type 1 and Insulin Growth Factor 1, that Cigna refuses to give medication and he may die if he doesn't get it. All of their doctors have pleaded treatment. The amount of cases is in the thousands. However, Cigna decides what is "best."
     
  5. KatieSue

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    Our doctor just writes the prescription for more than we actually use - in your case they'd put maybe 55 units a day instead of what you really use 47. They did the same with strips the prescription says test 10 times a day, even though she rarely does that.
     
  6. swellman

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    I'm pretty sure we're all sensitive to these issues and understand exactly where you're coming from and no one suggested you were hording it.

    I personally don't think it's unreasonable for an insurance to deny breakage prescriptions - there are plenty of other life sustaining drugs out there besides insulin but, I would assume that, insurance companies wouldn't cover accidental loss for them either. I don't think it's unreasonable for them to assume you're sending insulin back and forth as I'm sure it's done by many, many people.

    Just have the doctor re-write the prescription for more than you need.
     
  7. caspi

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    That's the problem -- Cigna often audits records to see exactly how much insulin is being used, leading medical providers leery of overwriting the rx.
     
  8. swellman

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    What records? Just curious.
     
  9. KatieSue

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    I was curious too as to what they would look at.
     
  10. caspi

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    Apparently from what I understood from our CDE when they did an "audit" they wanted to see the medical records of the patient, including any log sheets, etc.
     
  11. swellman

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    They would have to be magical to see our log sheets .... just saying. Do we sign a release of our records to the insurance companies as a rule? Again, just curious.
     
  12. caspi

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    From what I understand, the insurance company is privy to all of our medical history and information, are they not?
     
  13. swellman

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    I can't imagine without a signature but I fully admit I sign pretty much everything so ... in the end that may be true.

    I will also admit that, to this date, I have always felt a partnership with our insurance companies - not an adversarial one. I also admit we may have been very, very fortunate.

    As for the log sheets, they can't see what isn't provided.
     
  14. sincity2003

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    We don't have Cigna...we have BCBS Anthem and they use Express Scripts/Medco and we are forced to do mail order, but I will tell you, they aren't any better! Our prescription is for 750 test strips per 90 days. When we got our first order (this is fairly new to us insurance, as DH changed jobs), there were 700 in there. When I called, they did the same "counting" thing that you're talking about with the units of insulin. They said, oh, that's an 88 day supply and I said, "So what 2 days should I NOT test him?" and they said, "No, you can order early." It's just one of many instances where they've decided what is best for my son and not his endo that we trust a lot more than the insurance company ! Well, 700 for the summer is fine, but once school starts, we need that extra 50 to send to the school. We are now going through the appeals process to get the extra 50. We've also had other issues with their shipping policies, but that isn't your question.
    Right now, we use 1 vial of Humulin N, 1 vial of Humulin R and 1 Novolog pen each month and they are okay with that.
    I'm sorry you're having so many problems with them :(
     
  15. Michelle'sMom

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    Somewhere in the mass of forms you signed, there was an authorization to release information to your insurance company, who the most likely shared at least some of it with the Medical Information Bureau.

    How does your endo/CDE determine anything without seeing BG logs?
     
  16. swellman

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    We don't have a CDE. We dropped the CDE when they tried to tell us what pump to use and took hours and hours of our time at the onset of pump consideration. I guess he, the endo, takes my word for what I ask for and uses our A1c as evidence of control? I don't know - we have never, ever submitted a log with the two endos we've had ... ever. Even our Dx endo. I've always thought we had a really good relationship with our endo and that we discussed everything needed at our quarterly and that he was convinced we were doing well.

    Never, ever had a log to submit and was never asked. IDK. To be honest I feel most of our time is spent asking me stuff and not the reverse.
     

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