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Forced Formulary Changes

Discussion in 'Insurance Issues' started by Jeff, Feb 21, 2012.


Has your health care payer made a change that required you to change products or pay more?

  1. Yes

    34 vote(s)
  2. No

    8 vote(s)
  3. I don't know

    0 vote(s)
  1. Jeff

    Jeff Founder, CWD

    Jun 1, 1995
    With states and insurance companies scrambling to reduce costs, there are more and more instances of payers changing coverage or restricting products. A recent extreme example was Washington State, which considered limiting the number of glucose test strips to one per day for kids with type 1 diabetes on Medicare. Thankfully, that propsal was rejected, but only after enormous effort on the part of prominent health care professionals and families in the state.

    There are more examples, including a major provider in Massachusetts deciding that they will cover only one kind of glucose meter and strip. That's fine if you use that product, but if you don't, you must either pay a much higher amount of switch involuntarily. (For users of Medtronic, Animas, or Roche insulin pumps, the glucose meter and strip system doesn't communicate with the pump.)

    CWD has always supported patient choice for all diabetes care products. No one product is the best answer for everyone, and choice helps foster competition which results in improvements in the products that our families use to care for themselves. (You'd never want to go back to the products used in 1989 when my daughter was diagnosed, for example. The best glucose meter took 120 seconds to produce a result.)

    I'm curious to know how widespread this phenomenon is, and what kind of impact this is having on CWD families. I'd appreciate your thoughts and experiences.
  2. HBMom

    HBMom Approved members

    Jan 29, 2008
    Had to change from Novalog to Humalog. So far it seems to be ok, but still not happy that we had no control over the issue (unless we wanted to pay an arm and a leg for the novalog).
  3. Lisa P.

    Lisa P. Approved members

    May 19, 2008
    So far we're seeing large increases in premiums and forced switch of pharmacy (to a pharmacy that labels our syringes "Use to test glucose 7 times a day" :eek:). I believe we had an increase in copay percentages but since we have little choice but to pay I've not tracked it well.

    A friend had to drop her insurance entirely because the premiums literally doubled this year. She finally found another plan with a high deductible they could manage for now.

    No surprises here, of course, we'd anticipated more restrictions and higher costs and we weren't disappointed. It has been a real burden for our house, which has no benefits through work so pays all premiums and medical out of pocket out of a very low income and family gifts. Good luck addressing this.
  4. KatieSue

    KatieSue Approved members

    Oct 5, 2010
    We had to switch pharmacies. We must do Caremark mail order. I don't really mind except for some reason when the Doctors office sends in a prescription it never seems to get there - they have to call it in.

    We use Omnipod and the freestyle strips are a much higher copay now than others. We pay the difference for now just for the convenience.
  5. selketine

    selketine Approved members

    Jan 4, 2006
    We have Kaiser Permanente HMO coverage and they generally have given us only one choice as to pump type or meter type, insulin (novolog rather than humalog), etc.

    I realize this sounds bad but they do allow the doctor to write a script for a different product if there is a medical necessity. I have generally always been happy with their preferred brand - Animas pumps, novolog (though they paid 100% of the cost of humalog and the dilutent when William was little cause you couldn't dilute novolog), and the One Touch strips (go with the Ping). I can choose what infusion sets to use.

    They allow you to go over the "average" number of strips if the doctor agrees you are using X per day (so if you use 8 or 20 a day they multiply that out and you get a 3 month supply).

    For the cgms they don't have a preferred vendor so I was able to get a Navigator at first - now a Dexcom. And Kaiser was one of the early adapters to paying for cgms systems.

    They are also paying 100% for most things so I am not complaining. I realize choice is a good thing - but I think Kaiser has done a good job of holding down the insurance costs (it is the LEAST expensive option on my husband's list of choices), using well known/trusted products, and allowing people to go "outside the approved list" for medical necessity - and paying 100%

    I don't know why plans like BCBS cost SO much more but seem to cover way less. They have after hours care (when William has an asthma attack at 10pm - very helpful - I don't have to go to the hospital). I've just been super impressed with Kaiser and their way of doing "preferred" vendors.
  6. MomofSweetOne

    MomofSweetOne Approved members

    Aug 28, 2011
    We have Medco for prescriptions, and they have a "non-preferred tier" for which the copay is $80. Guess what!?!? They rarely have to pay out on things like ketone strips. The same higher copay is true for the One Touch strips. We use an Accu-check meter even though it doesn't communicate with the pump to save the $120 extra per year.
  7. TheFormerLantusFiend

    TheFormerLantusFiend Approved members

    Sep 10, 2006
    My policy changes my copays every year. The formulary changes have not affected me but what I pay per shipment has tripled in the last five years- I was being asked to pay $15 per prescription, now $50 per prescription. This is despite the fact that I am now using a number of things that make the total cost- what I pay for my prescriptions plus what insurance pays- less than it was five years ago.
    For instance, I use Regular instead of Novolog- that's a savings to insurance of roughly $600 per year. And I'm using more syringes instead of pen needles- a savings to insurance of roughly $35 per year. And I'm using enough fewer test strips because of the CGM that my CGM usage is not costing them money.
    But my costs are up.
  8. Michelle'sMom

    Michelle'sMom Approved members

    Aug 21, 2009
    We were notified in Oct 2010 that BCBS TX would no longer cover our One Touch strips, even though the meter/remote is paired with the Ping. If we hadn't switched, we would've paid the highest co-pay plus the difference in cost between One Touch & their preferred brand.

    We were trialing a Contour USB at the time, so we made the switch.

    I'm holding my breath waiting to see how much our policy will change, & how more it will cost after April 1. Last year's increase was 62% but thankfully, no change in copays or deductibles.
  9. GaPeach

    GaPeach Approved members

    Dec 29, 2007
    Our insurance company does not "prefer" One Touch strips but "prefers" the Ping pump. Go figure!

    We had to get a prior authorization (PA) to use the One Touch Strips. Every year we have to have the PA reapproved.
  10. Amy C.

    Amy C. Approved members

    Oct 22, 2005
    I use BCBS of Texas and get the One Touch strips and have since 1997. I believe your company's contract with BCBS is what determines what is covered. I am not sure how that helps though.
  11. Mrs. Russman

    Mrs. Russman Approved members

    Apr 20, 2007
    Ben is covered under the Children Health Insurance Program of Texas. We have options of plan carriers to choose from.

    In December the health care plan Ben is on forced all diabetes patients to switch to TRUEresults meters. Only 100 test strips a month of the approved test strips.
    NO consumer choice in meters. We switched to give it a try and HATE the new meter. Either you use their meter and strips or pay 100% out of pocket.
    Fortunately I found a 'loophole' and am able to switch health plans to one that still allows patient choice. (for now)

    We have heard of people being denied insulin pens. only allowed vials because pens are only for convenience.
  12. Seans Mom

    Seans Mom Approved members

    Oct 10, 2007
    We have to pay more for our supplies and have had to switch test strips because our preferred brand is now top tier. Of course that's all on top of higher premiums too. :mad:
  13. kathweaver

    kathweaver New Member

    Nov 3, 2013
    Express Scripts

    Was Medco, now Express Scripts

    They are now saying Humalog only and One Touch only.

    I am allergic to Humalog, and have terrible itching when pumping on it, also horrible blood sugars on it.

    Really scared, as I've talked to a pharmacist and they don't have an answer except I have to pay for my insulin out of pocket.
  14. kimmcannally

    kimmcannally Approved members

    Feb 28, 2010
    We had to switch to Bayer products for testing, when we had been using (and very happy with) Accu-chek.
    Co-pay for pharmacy supplies quintupled from $5 to $25. $25 still isn't a whole lot to cover three vials of insulin, compared to paying out of pocket price, but it is a HUGE jump from $5!

    I certainly can't complain, though, as our DME is covered 100%.
  15. Nancy in VA

    Nancy in VA Approved members

    Jul 16, 2007
    We have seen an increase in premiums, deductibles and co-pays. We used to get 100% DME coverage but now have a huge deductible, even the annual labs we did last month now have a co-pay. And all that even after the premium went up

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