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Insurance not paying for all insulin we need

Discussion in 'Parents of Children with Type 1' started by libbymom, Apr 30, 2013.

  1. libbymom

    libbymom Approved members

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    We have good insurance, I thought. United Health Care. My son started pumping 7 months ago, and at the time, we were using Humalog. I wasn't concerned with the amount that insurance would allow us because we had so much stockpiled from the past 18 months that we'd never use it all before it expired.

    Well Humalog wasn't working well in the pump, so we switched to Novolog about 6 weeks ago. Insurance agreed to pay for 3 months at a time, and the endo wrote the script for 4 vials. I quickly discovered that 4 vials wasn't going to be enough for the entire 3 months. When we went for our check up 2 weeks ago, I told the endo. She gave us 2 sample vials and said she would call in a new script for 6. It wasn't up for refill until today, but when I went to get it, the pharmacist said insurance wouldn't allow more than 4.

    I called the endo's office, and the nurse called insurance. They told her that since dr.'s notes said he was using 32 units per day, that 4 vials would be enough and that's all they would cover. I don't think the nurse tried very hard to explain to them why we needed more. She said she would check again tomorrow and see if they would cover 5 instead of 6.

    At 32 units per day, in a perfect world, we might could barely squeak by with 4 vials. That would be if Ben doesn't need too many corrections or get sick, if every pump site lasts the whole 3 days, if we don't waste any, etc... Not going to happen, obviously.

    Have any of you been through this? Should I try calling the insurance company, or let the endo's office deal with it? Any advice? Thanks!
     
  2. obtainedmist

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    Tell the Dr. office that you need more and that they need to write the Rx for more so that the insurance will cover it! The Dr. will need to write a letter of medical necessity if the insurance company balks. Best of luck and don't let the Dr.'s office tell you how much you need!
     
  3. TheFormerLantusFiend

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    That's the doctor's fault.

    My doctor always puts a range and goes up on what I use. Like if I told him, I'm using 25ish units per day, he writes "20-35 units per day, as needed."

    You just need to call the doctor's office and ask for a new prescription.
     
  4. KatieSue

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    Ours writes ours for a little more than we actually use. Same with strips, that one is actually written for quite a bit more then we use so I just don't order as much.

    If he uses 32 units have the Doc write for 40 to give some cushion.
     
  5. libbymom

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    So even though the "doctor's notes" (that the insurance company has) said 32 units, they could just change it tomorrow? Sounds like from talking to the nurse, the insurance company would balk at that. Or do they even have the right to disagree with it if the dr. changes it?
     
  6. TheFormerLantusFiend

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    The insurance companies can and often do say that they won't pay for more than, say, 1000 units per day of insulin per patient. They can do that.

    But if your doctor just wants to change your prescribed dose, insurance can't complain or stop that.
     
  7. Beach bum

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    Sounds like the nurse is confused.

    We have UHC, and per our plan, we have to get our continually refilled (ie. insulin, strips) supplies through mail order, which is now Optum RX. With UHC, you can get 2 refills on a scrip, but after that it's 100% out of pocket. BUT, if you go through mail order, all is covered. We get 6 bottles every 3 months through mail order, Novolog no problem.

    If the nurse says it can't be done, I'd first call the pharmacy and see what decline code the insurance company is giving and then call insurance yourself. Pain in the butt, but you will probably be able to get it straightened out.
     
  8. Nancy in VA

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    Emma's TDD has never been more than 20 and I think the nurse writes for 45-60 units a day. With pumping and priming and tubing, you can't base it on TDD.
     
  9. obtainedmist

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    If the insurance won't cover a new prescription amount, appeal by having the Dr. write a letter of medical necessity. We had to do that with test strips.
     
  10. swellman

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    The endo should write the Rx as necessary but, in my opinion, 4 vials in 3 months for a 7 year old seems like plenty. That's our Rx for our 12 YO and that allows for an extra at the school.
     
  11. mocha

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    I add in a buffer with my endo.

    I change out every 3 days, so that's 20 units lost in the tubing each time, which is 200 u/month.

    Then there's 10 u left over in the cartridge each time you change that, and I change those around every 1.5 days, or 200 u/month.

    Then we look at my total daily dose, take the high range, and then say I use 15u more per day than that number.

    And then I squeak by.

    Sorry the system is being poopy.
     
  12. Ali

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    Agree with this. As smart as my Endos are I have yet to meet one who got that the amount of insulin you use daily has little to do with what you need to keep a pump running. I agree add in an extra 10 to 15 units a day to cover pump priming, bubbles and bad sets. :) ali
     
  13. sarahspins

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    Doctors orders can be changed, so yes, that's all it would take... but what it comes down to is a simple math problem. The RX may say 2 vials a month, or 6 for 3 months, or whatever, but if your doctor lists a daily amount on there (or the Pharmacist calls the doc to get that number) when the Pharmacist does the math at 32u a day, they come up with a number of vials that is much fewer, and that is what they will dispense because that is what the order is actually for.

    Always ask for the script to be written for the exact number of units a day that the number of vials you are requesting works out to - so if you want 2 vials a month, that's 66u per day... your actual usage is kind of irrelevant, so long as that number includes what you use plus what you waste, that way when the pharmacist does the math there is no confusion and no possibility of being shorted because that's how the order is written. There's no confusion, and no problem getting what you need. My RX doesn't list the number of vials, it just lists the units (I get 3 a month, so mine says up to 100u a day, my actual usage is about 45-50, but 2 vials definitely isn't enough for me in a month - I would run out a few days early when you consider waste).

    I remember the frustration once of trying to explain to the pharmacist how so much insulin is "wasted" by pumping, between priming the tubing, and any insulin left in the reservoir (which could be up to 30u, if I am trying to avoid having to change it out at an inconvenient time)... so that's up to 50u wasted every 2-3 days... over a month that CAN add up to about half a vial... so yeah, shorting me a vial makes me run out before the end of the month, which is a BIG problem :)
     
  14. Sarah Maddie's Mom

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    This ^^^ As others have noted the prescription need to be written in units per day which should be your TDD + some % to cover pumping waste, and a reasonable buffer against spoilage, loss, breakage.
     
  15. Beach bum

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    And don't forget when you mistakenly pull the plunger of the cartridge too far out and you get showered with 187u of wasted insulin...oops:p:eek:
     
  16. swellman

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    How long did it take to get the smell off?
     
  17. Ndiggs

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    simple math is telling me you are using roughly 110 units (including the waste per prime) per 3 day site. That equates to roughly 27 days per vial in a perfect world (which never happens, and assuming you are getting ALL the insulin out of a vile, which I can never seem to do. At a minimum based on your dose I would say 5 vials, more likely 6 would be needed.

    I would call and ask your nurse to include the prime ammount into the TDD as that will change the math and get you into the extra vials, as I am sure that is were the problem is. If its 10 units a prime, and a site change every 3 days that is 300 units of wasted insulin right there. if every 2 days 450 units.

    Sad that we "waste" that much insulin when you look at it like that
     
  18. mmgirls

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    or how about needing to put more insulin in the cartridge in a hurry and you just pull out the cartridge, saying in your head that you will rewind it next while you grab a new tubing.

    fill cartridge with the last of the insulin in the vial, connect new tubing and stick it back in the pump.

    Then start to wonder where the insulin smell is coming from? O,yah

    I did not rewind so the last of the insluin has now just pushed tru the tubing and is on the floor and i am back to having just 15 units in the pump going out the door for a longer than usual night.

    ended up having to run to CVS while she was a dance class!
     
  19. libbymom

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    If we were still on MDI, that would work, as his TDD is usually 25-30 units per day. But with pumping, we can't get by with 4 vials per 3 months. Maybe I'm doing something wrong, but a vial will barely last 3 weeks, and that's if there's no accidents, site failures, etc.

    Thanks everyone for the info and advice. It's helped a lot. I'm waiting until after lunch to check with the endo's office to see what they've come up with.
     
  20. mmgirls

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    a few things.

    you do not have to fill the whole cartridge, just enough for 3days and priming/bubbles.

    if a site goes bad you can still use the same cartridge/insulin that the bad site had.

    those two things might help if you are not already doing so.
     

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