AskNadia: Medicare Stopped Covering My Novo Nordisk Insulin
Dear Nadia,
My mail order company that fulfills my insulin orders just informed me that I can no longer get my Novo Nordisk insulin? They said that Medicare will only cover Eli Lilly’s insulin. Should I choose to continue to buy Novo Nordisk’s insulin, my co- payment will be $200 for my prescription.
My insulin preference is Novo Nordisk because I tend to experience more hypoglycemia episodes when using the Eli Lilly insulin.
Ed
Dear Ed,
How wonderful for you to have refined which insulin works best for you when it comes to diabetes self-management. People do respond differently to the insulin brands; from hypoglycemic episodes to getting allergic skin reactions when injecting.
Since your pharmacy informed you about the insulin formulary, ask them to provide you with information on how to reach out to the Medicare plan to discuss your drug coverage. Then reach out to the plan and request “Evidence of Coverage”. Read this carefully and call them should you need clarification on the description of benefits.
The good news is that you can appeal Medicare coverage for your Novo Nordisk insulin. When speaking to the plan request the “Medicare Prescription Drug Coverage and Determination”. This is going to be the form you complete and submit in asking Medicare to make an exception for your Novo Nordisk insulin coverage. Additionally, speak to your prescribing physician to discuss your appeal. They will need to support your claim as to why an exception should be approved.
Once you submit your request, expect to receive a response in 72 hours.
I have included a link to the pdf form below so that you have an understanding of what will be asked of you and the options that are available for coverage under the exception clause.
REQUEST FOR MEDICARE PRESCRIPTION DRUG COVERAGE DETERMINATION
You might also be interested in reading these related Medicare coverage articles:
AskNadia: Why Medicare Covers Some Insulin Pumps
AskNadia: Why Doesn’t Medicare Cover the OmniPod Insulin Pump
Source:
Disclaimer:
Nadia’s feedback on your question is in no way intended to initiate or replace your healthcare professional’s therapy or advice. Please check in with your medical team to discuss your diabetes management concerns.
About Nadia:
Nadia was not only born into a family with diabetes but also married into one. She was propelled at a young age into “caretaker mode,” and with her knowledge of the scarcity of resources, support, and understanding for people with diabetes, co-founded Diabetes Interview now Diabetes Health magazine.
Nadia holds 14 nominations for her work as a diabetes advocate.Her passion for working in the diabetes community stemmed from her personal loss. She has used her experience as a caretaker to forge a career in helping others.
Nadia has been featured on ABC, NBC, CBS, and other major cable networks. Her publications, medical supply business and website have been sited, recognized and published in Herb Caen, WSJ, Ann Landers, Lee Iacocca, Entrepreneur magazine, Houston News, Phili.com, Brand Week, Drug Topics and many other media outlets.
As a pharmacist I see this every day. Big bucks in “kick backs” to the provider of coverage means big profits to shareholders of the stock.
I personally think it is sick, but it continues on and on. Even oral drugs for type 2 is a guessing game.
I do, however, understand the market place when a “manufacturer” takes 2 cheap OTC’s and makes a brand name that cost over 100 times more that purchasing over the counter.
These medications should not be paid for. As a Pharmacist I take an aggressive approach in this case and explain the ripoff.
Is it Medicare or is it the insurance company? When open enrollment comes, research the drug coverage on all the Medicare Advantage insurance plans offered in your area. In fact, as a special needs person, you might not have to wait for open enrollment. Surely one of them will offer better coverage than you have now. The insurance companies make deals with the pharmaceutical companies and then offer those products they can make the most profit with. Different insurance companies = different deals. I have to make sure both levemir and humalog are covered for me; tho this year with going in the donut hole in Feb because of the high cost of insulin, it was almost moot.