Humalog Coverage under Anthem

I’ve been fighting with Anthem for six weeks to get them to cover the amount of Humalog I need per month. Their formulary allows for three vials and I need five. My endo has sent an appeal letter and I’ve asked for a reconsideration. Does anyone have advice on how to get them to approve Humalog in the amount needed? I’ve had T1D for 23 years and have never had so much trouble getting my insulin.

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I’ve occasionally contacted my insurance about an item and been told I needed special authorization or a preauthotization for them to review - I think that’s different from an appeal.
Of course I don’t know what you’ve tried so far but you could ask specifically what they need your doctor to provide and any details of what must be included, such as ## months worth of medical records documenting the need for the increased dosage. You would think they’d reach out for that on their own but :confounded:

I’m so sorry. How the bleep do they know how much insulin your body needs? That’s completely insane. I once had to fight with our insurance company because my daughter’s needs had increased dramatically and they wouldn’t send more because it wasn’t “time” yet according to the old script. The doctor wrote a new one for more, which they were happy to fill — but not until after the date on the old one said it was time. Our doctor’s office ended up giving us a vial to tide us over, which was awesome of them, but presumably not how this is supposed to work!

@epowell Welcome Elizabeth to the JDRF TypeOneNation Forum!

I have not been a member of Anthem so I’m not aware of quantity limits of your policy. If the prescription quantity is not honored and your appeal doesn’t produce value, you have other options.

Insulin Lispro is marketed by Lilly and priced as generic - $168 per vial as opposed to $325 per vial [Walgreens list prices] and is exactly the same as Humalog - the insulin comes out of the same “vat” and only has a different label. Your doctor should have led you to this a couple of years ago. Lilly has announced another price reduction for coming soon, if not already.

One issue I have had in the past deals with how they write the prescription. When I was using syringes and pens I had a doctor write a prescription for something like 48 units/day (doing the math it works out to 14.4 cc s or about 1 and a 1/2 vials of insulin/month. The insurance would only authorize 1 vial per month when written like this. I had a long talk with an insurance representative and they recommended that my doctor actually write the prescription as vials/month or 3 vials /2 month. Unless it’s above a certain number of vials the insurance won’t question it. If the doctor actually writes units/ day they will take that as the maximum and generally under supply

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It’s also 100% true that sometimes you’ll need more insulin than others — and if you happen to have a string of heavy-need days all together, you could end up short in any given month. Make sure your doctor understands this, and writes the script for the maximum amount you could possibly need in that time period, rather than for the average amount. If you have extra, great: you can wait a few more days before refilling. Far better that than the alternative.

Of course, none of that matters if the insurance company decides it knows best how much insulin your body needs, and refuses to pay for more than x vials, which is how this thread started. Grrr.

If that’s the situation, then you’re left with paying out of pocket, appealing the decision through the insurance company process, lobbying your legislators, and seeking out free or reduced-price programs and community clinics. Again, grrr.

@MikeW This has been my experience as well. The language used on the script is how the prescription company fills the order. For example, I had a script for test strips which said “test 4-7 times per day”. My prescription was filled for 4x30 or 120 strips. I had the doctor re-write the script to “Test 10 times a day” and they filled it for 300 strips. My advice: tell your doctor to think like a lawyer.

You might try Sanofi for you insulin pen needs. I get all my vials from them & it’s free. Hope this helps.