Moments of Wonderful

…rather than a lifetime of nothing special. A diabetes blog.

Moments of Wonderful - …rather than a lifetime of nothing special. A diabetes blog.

Step Therapy

Step therapy.

By that name you’d think I started a new exercise program. Not exactly.

New insurance means new preferred medications. Overall my new insurance is a nice improvement over my old plan and as good as can be expected in the current healthcare climate. The out of pocket costs for my new insurance are much better than my old, but they have some “different perspectives” about what they should cover.

First, iBGStar strips are not covered at all. I really like the iBGStar meter (and carrying a smaller purse) but I have to keep the bottom line in mind and it is not financially responsible to pay for strips when there are brands that are covered. I’ve already been in contact with my local Sanofi rep. His unofficial advice was to not hold my breath.

blue apidraOf course, the second issue is the coverage for insulin. I have been taking Apidra for a little more than five years. On my old insurance, it changed tiers a few years ago. Paying extra for an insulin that is predictable and reliable in my body was a cost I was willing to pay. Sanofi has a discount program that also helped for the past year.

I was curious what tier that Apidra would land on in my new insurance and apparently it is on it’s own “step”.

In their words –

Step Therapy programs require a trial of a “front-line” medication before a more expensive “back-up” brand-name product will be covered.

That’s funny – both products in this case are brand-name, aren’t they?

It does feel like the insurance companies are trying to play both sides of the table at this point. If it is so easy to suggest exchanging one insulin for another, then they must be extremely similar. Otherwise, it would be dangerous for a company (not a doctor) to suggest that taking one would be just as easy as taking another. Right?

But on the other hand, if the insulin brands are similar enough to switch then why do two brands receive “front-line” status while a third is a “back-up” product?

Thankfully the insurance company does offer some advice to my doctor –

The information provided is only a guideline to assist you in planning the best course of therapy for your patient and does not replace your clinical judgment. We hope this information is helpful.

I know I’m not the first to face this decision and I think it makes me even more frustrated.


Just scheduled my first appointment with the new endocrinologist. We’ll see what he has to say about all this.

Category: insurance
  • Scully says:

    every time i read about these things I get so confused. I don’t understand how insurance companies can have drug preference.
    I really hope you can continue using what you’re used to.

    March 4, 2013 at 6:59 am
  • Mike Hoskins says:

    This annoys and enrages me beyond belief – the whole notion of insurers dictating care, rather than a doc. And yes, they can hide behind boilerplate disclaimers about this only being “guidance” but we all see past that for what it really is… a threat. That they won’t cover this, and can basically do whatever the F they want, and we’d better just convince our docs that what the insurance company’s coverage looks like is best for treatment. Hate it.

    March 4, 2013 at 7:16 am
    • katy says:

      and Sara’s company is so smug about it!

      March 4, 2013 at 8:23 am
  • Mike Hoskins says:

    Good luck navigating this, by the way, Sara. Hope you can get the Apidra.

    March 4, 2013 at 7:16 am
  • katy says:

    wouldn’t it be so refreshing if they’d instead say, “we enjoy higher profits when more of our clients use insulin Z, so if you and your doctor strongly prefer insulin A, you will have to prove how much you want it by jumping through these hoops. In this way, we offer a good value to our shareholders while obeying all current laws.”

    March 4, 2013 at 8:22 am
  • StephenS says:

    Sara, I know you probably don’t want to do this, but you might want to go to a) your insurance carrier, or b) your employer, if they’re self-insured. Make the case that they’re not going to be paying a significant amount to cover your Apidra anyway. If your employer’s plan is self-insured, they’re paying the claims anyway. So make the case that a happy employee is worth the effort. I agree that paying for one insulin and not another is kinda stupid, but maybe no one ever told them that before. The worst they can do is say no. Good luck, however it turns out.

    March 4, 2013 at 10:54 am
  • Scott K. Johnson says:

    Ugh. I hate this sort of thing. I think your line, in parenthesis, says it all “(not a doctor).”

    March 5, 2013 at 5:42 am

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