I was just notified by United Healthcare that for 2024 they will not be covering Lyumjev or any other Lily insulin product (Humalog, Lantus). It took me almost 2 years to figure out Lyumjev with my pump! It wasn’t easy and I finally got things under control. Now, because of insurance contracts with insulin manufacturers, I need to change back to Novolog. I tried hard to keep Novolog 2 years ago and even with appeals, the insurance would not cover it.
Are there ways we can stop this back and forth? These insulins are not interchangable! It takes so much time and effort to stay stable. Companies bid for these contracts and if a bid is unfavorable to the insurance company, patients are the ones who suffer the consequences!! I am a nurse so I see this from many perspectives and it is just wrong.
Ask your Dr to file an appeal on your behalf with your insurance company for the prescription you need. I recall hearing it’s a multi-phase process, but if your Dr keeps responding then by the time it gets to the last step the insurance company will cave (or they risk being sued and all that documentation can be used against them). It’s time consuming but sounds like it would benefit you.
Insurances apparently go with the medications for which they have negotiated the best pricing, with little or no regard for patient needs: a few years ago I was notified that my plan was switching to an insulin that was not even approved for pumps ! A lot of endos were feverishly going through the process of documenting medical necessity so their pump patients could continue getting our medication.
It may not be common, but some insulins simply do not work for some patients, as is the case for you. Your doctor should know how to compose the documentation, so no need for you to write anything - just let them know you need one and they will take care of the rest.
BTW, open enrollment is now in place or will be soon - you could take the opportunity to check into other plans.
I wish it was that simple. Insurance denied all MD appeals due to medical necessity. The insurance co would not budge. So yes! I could go to a different insurance from the only one offered by my employer and pay $850-$1000 per month premium for insurance that covers my insulin. Or, I could just pay out of pocket for the insulin I need. Or, go to Mexico or Canada and purchase the insulin I need. Those were my choices.
Yikes! If you have to go out of pocket check the Goodrx app - it gives you prices for medications at local pharmacies so you can compare out of pocket costs. A cartoon of 5, 3ml Lyumev kwikpens of 100 units ranges from roughly $250-$600 in my area. There are often coupons available.
Good news is Lantus is made by Sanofi so maybe it won’t be affected by the changes. Message your doctor or schedule an appointment to go over the changes. Novo Nordisk’s rapid acting insulin is Fiasp so your doctor may talk to you about trying it.
Try calling Lilly, 1-833-808-1234, to find out what their Saving Card available at https://www.insulinaffordability.com/ is actually going to do for you Their website uses the wiggle words “as little as $35”.
You can also talk to your HR Benefits Coordinator person and ask if there is an option to get cash instead of health insurance that you can then use to pay for your own plan. In my experience the amount isn’t worth it but you’ll have the opportunity to have a conversation about how their selected plan isn’t working for you and ask them to consider different choices in the future.
Thanks. I’m quite familiar with the options as a clinician and as a patient. My question was more along the lines of how can we stop this practice? As a clinician, HOURS are spent on appeals. If the clinician didn’t think it was medically necessary, they wouldn’t be prescribing.
I don’t think my question was very clear. My apologizes. I’m a patient and a clinician. I’m very familiar with the barriers patients must navigate just to keep access to the card and treatments they need. i see it from both sides. I also fully understand the contracting process for insurance. I’ve worked in this environment for years. Decisions are not made by those who are educated and trained to treat disease, but costs. Period. My question is- how can we be heard? I spent 2 years fighting for access to a treatment that WORKED! Denied, denied, denied. All based on $$$ and the bids weren’t much different from each other.
Is there a forum through this organization where we can have our voices heard?
It is so ironic that suddenly I will have access to the treatment I needed all along! After 2 years, I can go back to the treatment that worked but not because they listened to me but because
Hi @Catham , this is a self help forum with non-professional participants sharing their experiences, This is not an official JDRF service organization. Perhaps you can get help from the ADA or from direct contact with a patient advocate.
I have only heard through others that sometimes legal action is required after denials. My insurance company has (for example) an avenue to dispute a denial which can include legal representation or arbitration. I hope you find the answers you are looking for. Good luck!
A person’s access to the medication they need, should not change because their insurer got a better bid this year from “X” than “Y.” Unfortunately the negotiators likely are not medical professionals and their concern is simply the bottom line. My only suggestions are to write your congressperson, contact the ADA, and let your company’s benefits department know. A large company may have more influence over offerings than a small one, but a small company might reconsider the provider they choose in the future.
Try asking on an economics forum if a respected economist has a theory on how to change the market pressures on the heathcare industry in the US then look for a group that is promoting that theory to people in charge. JDRF does influence policy changes, start here to find out how you can participate: Get Involved With JDRF & Take Action Against T1D
Your question includes a story with a PBM as a character. If PBM’s are interesting to you I suggest listening to Wait, what's a PBM (and how do they work)? - An Arm And a Leg The episode is a bit of a tease but if you are driven to action you can follow up on what is mentioned to find out if there is more you can do.
You will be more effective at achieving the change you want if you work on communicating clearly. Know your audience, have a structure and revise often. Depending on your learning style there are lots of online resources. I know from personal experience there are lots of college and university professors willing to talk to anyone during office hours because students don’t show up as much as they need to.
I went through this long ago. I became unstable with the change, using double the amount of insulin & still battling high blood sugars. Working closely with my doctor who collected the data & presented it to United Healthcare, they agreed and relented.
Make sure your doctor is in the battle with you & fight the good fight. I believe you can win if you and your doctor work closely together. I have NEVER been able to tolerate Novolog.
Your best bet is to take your scenario to your local congress representative. Talk to their local and DC offices. Write letters to other congress persons who are on the healthcare/insurance committee. And also go to your state department who’s job is to make sure insurance carriers are providing adequate healthcare services for their members.
I just checked the UHC Medicare drug formulary and Humalog pens and vials are indeed covered, at least for Medicare Advantage and Part D members. Plus we have the cap on the copay of $95 for a three-month supply. Lantus is also covered, but as others have written, that is not made by Lilly. If you’re not Medicare eligible, then, as many have said in this thread, have your doc file an appeal with UHC pronto - now, rather than in 2024.
Same. I just got notified that Fiasp is no longer covered and that the “equivalent” is Humalog. Nope. I spent the better part of this year getting Fiasp approved with letters of Medical Necessity and Prior Authorization. It’s a load of horse sh*#.
I don’t know if pharmacy benefit managers have anything to do with the issue you have but this might be something to look into. I’m not personally familiar with the group but it sounds like a grass-roots organization fighting for patients’ rights. You might find some resources or even opportunities for advocacy.