Insurance and diabetes
Erin Da Rosa, RD, LD, CDE
Navigating the complex insurance world can be frustrating and overwhelming, particularly for people with diabetes who interact with the healthcare system often. Our goal at the McNeely Pediatric Diabetes and Endocrine Clinic is to partner with our patients to not only help manage the variability in blood sugars- but to also help manage the variability in cost of medications and supplies.
Health insurance providers come in many forms, but they can be categorized into two major groups: privately owned companies and programs operated by the government.
- Commercial insurance providers are privately owned insurance companies that contract with business or individuals to help cover healthcare costs according to criteria determined by the company.
- There are several programs operated by the federal and state governments which are specifically designed to cover a certain part of the population, such as veterans, the elderly, those without employment, those without health insurance benefits offered by employer, or those with lower income.
Insurance companies offer a variety of plans and each plan works a little differently. It is important to contact your insurance company so you know how it works and what it covers. One important component to understand is how your insurance handles both prescriptions and medical supplies. There are some important questions you should ask so that you can be the best advocate for yourself and your child:
- Does my Insurance have a Pharmacy Benefit Manager (PBM) who manages the prescription side of the insurance?
- How much will I pay for my regular prescriptions?
- What are my options if the medication is not covered?
- Which pharmacy can I use?
- Is it better for me to receive prescriptions as a 30 day supply or a 90 day supply?
- Is there a Durable Medical Equipment (DME) Supply company that I can work with to get my Diabetes Supplies?
Our team wants to help minimize cost. We work with your insurance and pharmacy to choose the preferred insulins and supplies that will support your treatment plan. Insurance companies and PBMs update the formulary often throughout the year. If you find that you are paying higher prices than normal or have received notice that the formulary has changed and new products are preferred, contact our clinic and we can work to accommodate the change. When high costs remain even after choosing preferred products, we can use resources such as co-pay assistance cards offered by the manufacturers. These cards may lower out-of-pocket costs for prescription drugs and some supplies for eligible patients. You can obtain these cards online at the manufacturer website, through the pharmacy, or talk with a member of our team. In addition, there are assistance programs offered by manufacturers and/or non-profit organizations. We can refer you to those organizations for more information and to see if you qualify.
In some cases, certain products are recommended by your clinician over a product preferred by your insurance. When this happens, we submit a prior authorization and/or an appeal to explain to your insurance why a particular product is being recommended.
Diabetes management coupled with the complex health insurance industry is not always easy. However we are here to help ease the burden and provide resources so that you can continue to manage diabetes with confidence.