I just made an account, and I’ve seen a few posts about insurance difficulties, so I thought I’d write up some tricks I’ve learned to get all your diabetes-related stuff cheaper.
I’m a clinical pharmacist, diabetes educator, and certified trainer on a majority of pumps on the market. I also do public speaking for one of the CGM companies. I spent 13 years working in pharmacies and another 5 years full-time in medical clinics, so I’ve seen both sides of the process. I’ll keep things agnostic so I don’t sound biased.
The first thing to understand is that your insurance is fractured. There is generally your medical insurance and your pharmacy insurance, and they hardly talk to each other. Your medical insurance typically hires a pharmacy benefits manager to take care of pharmacy needs, and they give them money every month.
CGMs: These are increasingly going through pharmacy benefits and less through DME. Pharmacy benefits means (obviously) you pick it up at the pharmacy. DME means it goes through your medical insurance. If you have a separate deductible, wherever you get it from will apply to that deductible. Your pharmacy deductible applies at the pharmacy when you pick up your CGMs at the pharmacy. Your medical deductible applies when you get them through DME.
General trends I’ve seen with CGMs lately: Medicaid in the state where I practice requires one visit every six months, or they won’t pay for CGMs. That typically means that they’ll require a prior authorization, and those are almost entirely automated these days. The website gives the practice a questionnaire that we fill out, and so long as we click the “yes” box next to “has the patient been seen in the last 6 months?” It gets automatically approved in seconds. Then the pharmacy benefits register it as approved, you go to the pharmacy, and they’ll get a paid claim. That’s about as strict as it gets. Lots of plans will pay for it no questions asked, so long as you’ve picked up a single prescription for any kind of insulin in the last 3 months. It just flips a setting on the insurance side of things, and it goes through. The requirement for most plans (because it’s Medicare’s rule) is a single dose of insulin daily for type 2, and CGMs are covered. Because of that, most PBMs implemented the “auto” approval once insulin is filled
Insulin: Always pharmacy benefits except for Medicare A/B (not an advantage plan) on an insulin pump. Generally speaking, insurance will pay for up to 120 units a day without requiring your provider to do a prior authorization. My rule of thumb when someone is on an insulin pump is to send the script in with a higher-than-exact amount of insulin. For pump patients, you’re going to need an extra 15-20 every 3 days for tube fills. Insulin waste is going to happen, so if I send the script in for something like 20 units more per day than the patient needs, I never hear from them because they’re out of insulin. Pharmacy insurance calculates how soon you can pick up prescriptions based on day supply, and the pharmacy calculates day supply based on units/day.
Pump supplies: These are always DME (medical benefit). The worst policy I’ve seen is requiring a visit every 3 months to renew pump supplies. Most insurances require 6 months or a year. If you’re not sure what yours is, look up their policies or call. Find out what your insurance requires, and then when your provider says something like, “I don’t need to see you for a year,” you can tell them, “Yeah, you do, or I can’t keep getting pump supplies.” It’s a game, and insurance has written rules. Find out the rules and help your provider not break them. ALSO, when they’re sending the order in, they have to specify how often infusion sets are changed. I would, like with insulin, account for occlusions by writing them for half a day more. If that sounds too fraudulent for your provider, tell them to ask their sales reps for sample infusion sets. I worked at a clinic with a contract with two pumps that used tubing, and both companies happily sent us extra infusion sets and tubing. In a new training, I’d give the patient 4 extra sets because, on average, 4-6 infusion sets will have an occlusion every year. They’d be on auto-refills, and when the inevitable occlusion happened, they’d have extras, and we wouldn’t get a phone call… Except for that one time one of my patients’ houses burned down with everything in it. Our rep overnighted us a month’s supply of samples to take care of that person.
Pump “warranties”: They call it a warranty. They have good warranties. In reality, it’s also a contract. This only applies when it goes through DME, though. When it goes through pharmacy benefits, it doesn’t violate the warranty/contract. For those of you on Omnipod 5 or Twiist, those go through pharmacy benefits exclusively. The Tubeless Mobi and Beta Bionics Mint are also going to be targeting pharmacy benefits. You can be locked into a warranty on a regular DME pump (T;slim, Mobi, iLet, Minimed) and still switch to a pump that’s paid by pharmacy benefits in the middle of that warranty.
Hopefully this helps someone understand the mess that is insurance benefits when it comes to diabetes supplies! Lemme know what didn’t make sense, and I’ll try to explain it a bit.
