Your insurance cares about you--Act 2
The cell phone rang as I was unpacking the car. We’d just returned from a kindergarten field trip to McCall’s Pumpkin Patch. We were wind-blown, exhausted, and I was still trying to get hay out of my ears.
Deb answered then held the phone out to me. For you.
Juggling three pumpkins, I took the phone, which then made a strangled squawk to tell me the battery was low.
It’s Lujan from Pres. She a clinical nurse something or ‘nother
“ Hi, William, I’m just calling to follow up on an email we received from Life Masers. Apparently you don’t want to participate in our new diabetes program because you feel that we should be spending the money on providing adequate numbers of test strips instead?”
Yeah, that’s right. I’m sure your records show I’m a type one on multiple insulins. I should be testing ten times a day.
“I couldn’t agree more,” said Lujan.
I dropped the phone.
After setting down the pumpkins, picking the phone up, and plugging in to a charging cord, Lujan and I had a pleasant conversation.
Turns out Pres will allow up to 300 test strips per month for T-1s. Catch is you pay a co-pay for each box. That said, so long as you use their preferred type (AccuChek Aviva) they’ll give ‘em to you at $10 per box; which is really a pretty good deal. Of course, you have to get all 300 at once so you need to cough up thirty clams at the pharmacy. (Being a weeeeeee bit behind on my pharmacy tab I’ve been demoted to pay-as-you-go. OK, so maybe 690 bucks isn’t a weeeeeee bit.)
If I was still able to use my CoZmo pump they’d actually pay for FreeStyle strips. Wish someone had told me that back when I was still using my pump. You need a prior-auth, but it is always approved. Sigh. Why does insurance have to be so complicated?
She was sorry to hear I’d been caught in a plan with poor Durable Medical Equipment (DME) coverage. Apparently there are “thousands” of different Pres plans. Some treat D-folk better than others. “It’s a nightmare,” she tells me. More support for my fundamental belief that good insurance is really only offered to those that will never use it.
I didn’t think to ask her the question every pumper in the world wants an answer to: why the fuck are infusion sets considered durable medical equipment? There it nothing durable about them at all. Ya’ throw ‘em out every three days. Or four. Or five. Depends how poor you are and how much you are willing to risk an infection.
Back to teststrips. Lujan told me that teststrips are the sinlge largest expense for Pres of all medications. She also said they have been giving D-Folk more strips and tracking A1Cs to see if they improve with greater testing. Her official line is that Pres is willing to pay more up-front to save money on complications later; but at the same time the British study indicating that testing may be a waste of time is casting a long shadow. I feel a collective shiver across the diabetes landscape as that cold wind continues to blow down from Brittan.
She also tried to get me to switch from Humalog to Novolog; a change of $55 per box to $35 per box of five. Yeah, I used Novolog for years, but it isn’t doing the job anymore. The Humalog is. OK, well, nothing you can do about that.
She also told me that for some seniors caught in the “gap” of their Part-D coverage, many providers are having their Lantus/Levemir users go to Wal-Mart and buy ReliOn NPH out of pocket. This does not require an Rx. Feedback Lujan gets is that the old-school NPH is doing the trick for a lot of folks. Hmmmmmmmmmm….. I’m suspicious of that.
I’ve used NPH in the past. It’s a little… unpredictable. It also has a waaaaaaaaaay shorter duration of action than the two “L”s. Still, something to keep in the Break Glass in case of Emergency box. I snooped around online and found press releases stating that ReliOn brand is made for Wal-Mart by Novo. In fact, all three Novolin insulins (regular, NPH, and a 70/30 mix) are at your friendly neighborhood Wal-Mart for the alleged price of $16.94 per vial. Wal-Mart reminds us that they have ReliOn syringes and glucose tablets too.
I was really impressed with Lujan. Not what you expect from an insurance nurse at all. I wondered if she was one of us.
Can I ask you a personal question?
Long silence, then, “Sure.”
Are you a diabetic?
“No, I’m not, why?”
Well you’re doing such a great job for us, I figured you must be one of us. I’ll tell you what, I’ll make you an honorary diabetic.
Laughing, “I’m honored…. I think. At least I’ll have something to tell my family when I get home tonight.”
Congratulations, you’re now a member of the tribe. We’ll get you your T-shirt and Glucometer later.
Deb answered then held the phone out to me. For you.
Juggling three pumpkins, I took the phone, which then made a strangled squawk to tell me the battery was low.
It’s Lujan from Pres. She a clinical nurse something or ‘nother
“ Hi, William, I’m just calling to follow up on an email we received from Life Masers. Apparently you don’t want to participate in our new diabetes program because you feel that we should be spending the money on providing adequate numbers of test strips instead?”
Yeah, that’s right. I’m sure your records show I’m a type one on multiple insulins. I should be testing ten times a day.
“I couldn’t agree more,” said Lujan.
I dropped the phone.
After setting down the pumpkins, picking the phone up, and plugging in to a charging cord, Lujan and I had a pleasant conversation.
Turns out Pres will allow up to 300 test strips per month for T-1s. Catch is you pay a co-pay for each box. That said, so long as you use their preferred type (AccuChek Aviva) they’ll give ‘em to you at $10 per box; which is really a pretty good deal. Of course, you have to get all 300 at once so you need to cough up thirty clams at the pharmacy. (Being a weeeeeee bit behind on my pharmacy tab I’ve been demoted to pay-as-you-go. OK, so maybe 690 bucks isn’t a weeeeeee bit.)
If I was still able to use my CoZmo pump they’d actually pay for FreeStyle strips. Wish someone had told me that back when I was still using my pump. You need a prior-auth, but it is always approved. Sigh. Why does insurance have to be so complicated?
She was sorry to hear I’d been caught in a plan with poor Durable Medical Equipment (DME) coverage. Apparently there are “thousands” of different Pres plans. Some treat D-folk better than others. “It’s a nightmare,” she tells me. More support for my fundamental belief that good insurance is really only offered to those that will never use it.
I didn’t think to ask her the question every pumper in the world wants an answer to: why the fuck are infusion sets considered durable medical equipment? There it nothing durable about them at all. Ya’ throw ‘em out every three days. Or four. Or five. Depends how poor you are and how much you are willing to risk an infection.
Back to teststrips. Lujan told me that teststrips are the sinlge largest expense for Pres of all medications. She also said they have been giving D-Folk more strips and tracking A1Cs to see if they improve with greater testing. Her official line is that Pres is willing to pay more up-front to save money on complications later; but at the same time the British study indicating that testing may be a waste of time is casting a long shadow. I feel a collective shiver across the diabetes landscape as that cold wind continues to blow down from Brittan.
She also tried to get me to switch from Humalog to Novolog; a change of $55 per box to $35 per box of five. Yeah, I used Novolog for years, but it isn’t doing the job anymore. The Humalog is. OK, well, nothing you can do about that.
She also told me that for some seniors caught in the “gap” of their Part-D coverage, many providers are having their Lantus/Levemir users go to Wal-Mart and buy ReliOn NPH out of pocket. This does not require an Rx. Feedback Lujan gets is that the old-school NPH is doing the trick for a lot of folks. Hmmmmmmmmmm….. I’m suspicious of that.
I’ve used NPH in the past. It’s a little… unpredictable. It also has a waaaaaaaaaay shorter duration of action than the two “L”s. Still, something to keep in the Break Glass in case of Emergency box. I snooped around online and found press releases stating that ReliOn brand is made for Wal-Mart by Novo. In fact, all three Novolin insulins (regular, NPH, and a 70/30 mix) are at your friendly neighborhood Wal-Mart for the alleged price of $16.94 per vial. Wal-Mart reminds us that they have ReliOn syringes and glucose tablets too.
I was really impressed with Lujan. Not what you expect from an insurance nurse at all. I wondered if she was one of us.
Can I ask you a personal question?
Long silence, then, “Sure.”
Are you a diabetic?
“No, I’m not, why?”
Well you’re doing such a great job for us, I figured you must be one of us. I’ll tell you what, I’ll make you an honorary diabetic.
Laughing, “I’m honored…. I think. At least I’ll have something to tell my family when I get home tonight.”
Congratulations, you’re now a member of the tribe. We’ll get you your T-shirt and Glucometer later.
posted by Wil | 6:08 AM
3 Comments:
Your comment about the British study indicating that testing may be a waste of time casting a long shadow was applicable only to patients with type 2 diabetes, and its worth noting that the glycemic variability in patients with type 2 (even those using insulin) is significantly less than it is with type 1s. For what its worth, consider the following:
According to Dr. Zach Bloomgarden, who is noted for his huge diabetes clinical practice (more than 1,000 patients) in New York City, and also for his many articles on diabetes (nearly 250). Since 1994, he has also written over 150 columns, "Perspectives on the News" for Diabetes Care. Dr. Bloomgarden is currently a Clinical Professor of Medicine at Mount Sinai School of Medicine and a reviewer for Diabetes Care, Mayo Clinic Proceedings, the Archives of Internal Medicine, Practical Diabetology, Diabetes Management and Health Outcomes, Journal of Clinical Endocrinology and Metabolism, and Metabolism.
Anyway, introductions aside, Dr. Bloomgarden says "Type 1 diabetes is a hugely different burden from type 2 diabetes, and the easiest way to quantitatively understand that is to have a thousand patients or so with diabetes that you treat for years and download their meters day after day after day - when you do that, you'll find that the standard deviation of the blood sugars in a person with type 2 diabetes is 10 mg/dl or 20 or at most 30 or so. The standard deviation of the blood sugar of someone with type 1 diabetes is at least 50 or 60 and often 90 to 100. So that translates into just huge, huge variability in blood sugars. The frequency histogram of a person with type 2 diabetes, if you bother to do it, would be a very very narrow bell curve, and the frequency histogram of type 1 diabetes is sometimes like a square wave going from 40 to 400."
Anyway, consider yourself fortunate to have successfully navigated through the insanity of your insurance company. You accomplished more than many people do!!
I'd kill for ANY insurance right now but I also know that the stress factor of all the redtape would probably send me into a coronary, too...so it's a catch-22 of sorts.
I hope your experience and blog will encourage more D's and families to question and challenge insurance compannies. I did find out that some of the problem starts at the vendor (Minimed) when they code everything DME. It is apparently a long process to create or change a code in the CPT(?) manual( and they have no incentive to change it). I agree and used the same argument about infusion sets being disposable. I still have issues with being charged for tapes (IV3000, or the CGMS) I am not finished with my challenges/fights.
Kelly
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