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What to Do When You Need to Change Treatments

“For years, I used the same insulin pump. When my doctor told me that I would benefit from a different one, I wasn’t exactly sure how to handle that with my insurance. My colleague told me to check my policy—and I was glad I did! When the policy was confusing, I followed up with my insurance company and they explained that the newer pump was not covered, but I could apply for an exception. Because my doctor could show that it was medically necessary, the exception was granted.”
—T1D patient, AZ

In this section we’ll discuss

What to Do When Switching Insulin Types or Treatments

There are several steps to take once you and your doctor have decided that switching diabetes treatments is best for you. First, review your policy. If the language is not clear whether the new treatment is covered, call your human resources department or health insurance company (there should be a member services number on the back of your card). It is important to check the coverage status of the specific brand of insulin, insulin pump or continuous glucose monitor (CGM). If the new treatment is not covered, you can request an exception. Keep in mind that your doctor will need a medical reason to back up a request for a coverage exception.

Your Options for Switching Treatments

IF TREATMENT IS COVERED IF TREATMENT IS NOT COVERED

In this case, it likely won’t be an issue to switch, but you’ll want to consider a few things:

  • Make sure to understand how much it will cost you by reviewing the details on your plan’s formulary or by calling a member services representative at your insurance company. Even if it is covered, it may be at a different cost than you’re currently paying.
  • If the new insulin or other treatment is on a different prescription tier from your current treatment, or your insurance company has moved it into a higher tier, this will increase your out-of-pocket costs. If this is the case, you have the option to appeal or seek an exception to the change in your costs.
  • Does the new treatment require a prior authorization? See the “How to Obtain a Prior Authorization” section for more information and helpful tips. Will starting the new treatment require visits to your doctor to check your dosage or to learn how to use a new technology? These visits will entail costs to you.

In this case, you’ll want to consider a few things:

  • What are the pros and cons of staying on your current treatment?
  • Can you remain on the same treatment and remain healthy?
  • Are there any other alternatives that are covered?
  • What is the difference in cost?
  • If the treatment is deemed medically necessary by your doctor, you can apply for an exception to request that your insurance company cover the treatment. Find more information and tips in the “How to Apply for an Exception” section.

 

JDRF maintains a forum where insurance issues can be discussed.
If you have questions for the community, you can post them here!

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