Successful appeal or exception?

(Gretchen) #1

I’m trying to help a friend whose insulin was put onto a Tier 3 through her insurance carrier. The Tier 1 product doesn’t work as well for her and she wants to appeal to be able to switch back to the other insulin.

The carrier has told her that since it isn’t denied, she can’t appeal it. She can’t afford it at the higher Tier price.

Can she, with the support of her Endo, ask for an exception or is there any recourse?

(joe) #2

@gvan hi Gretchen, I don’t have actual experience here. I think she would need data supporting the “work as well” claim, and her doctor to put it in writing that the specific brand or formulation is medically necessary. since the only argument is about cost rather than coverage or non-coverage, it seems to be a really tough argument. the “medically necessary” thing carries a lot of liability.

if the company is large enough, or has something to lose in bad publicity, they could make specific exceptions for your friend. truth-be-told I am guessing. it would make a bigger difference with specifics: such as if the insurance company was actually saying that they only cover “NPH” at tier 1 and “Lantus” at tier 3, because of whatever. or if it is more like the insurance prefers Novolog over Humalog… good luck.

(Dennis J. Dacey, PWD) #3

Hi Gretchen @gvan,

There is some information that might help your friend, and sources listed for help in paying, in the Health Insurance Guide section under the Resources Tab at the top of this page.
I know under the insurance plans I have had, all rapid acting brand name insulins have been tier three - expensive. And to date, there are not any generic rapid-acting.

(Nancy) #4

Gretchen, my short answer is yes, appeal to ins co based on “the crap you offer at tier 1 doesn’t work which means higher coverage dollars for my uncontrolled diabetes”. Get all her docs involved - endo, podiatrist, ophthalmologist and gp.

Copy the State’s Attorney’s office.

File a complaint with the insurance commisioner for the state.

Contact the local Health Department for assistance getting the proper meds.

Contact the manufacturer for assistance getting the proper meds.

Keep pushing back!

Btw, three generics should hit the market within the year.

Best of luck!


(pamcklein) #5

Hi Gretchen,
How wonderful you are trying to help your friend! Yes, your friend can appeal, or to put it better, can ask her doctor to file an appeal with her insurance company (I have never had to contact them myself)… I have had to do this for meds that were not covered as “preferred” and have never had a problem. My doctor simply contacts the insurance and explains why I need this particular med. Suggest to your friend that she talk to her doctor and he/she should be able to take care of it for her.

Pam K