[hooverbw]

Hello all.

I have been using the Freestyle Libre sensor for almost 2 years now and it has been wonderful. I have been able to control my BG better and my A1c shows that. So now I actually got in with an Endocrinologist for the first time in 13 years and she has encouraged me to continue using the sensor.

Here comes the situation and the question. I have been paying out of pocket the entire time for the sensors, my insurance out-of-pocket maximum is met for the year and I would love it if insurance would finally pay for the sensors. When we submitted the request to insurance (Anthem) they said it was denied because I have to show a history of not being able to control my A1c in order to qualify. Unlimited finger sticks is perfectly fine, but something that works better with a very similar cost is denied. Having the sensors are what has enabled me to control my A1c (6.4 at last visit) up to this point. At my worst I reached 10+.

Does anyone have any tips/tricks to get insurance to start covering something that I have been using already for 2 years? Thanks.

 

[itissteve]

Your contract (if you will) with Anthem should include a description of how to appeal a rejected claim. It probably also includes information on which medical devices like the Libre they cover (and to what extent).

Enlist your endo and your general practitioner, if possible, to write the appeal on your behalf. I'm sorry, but their words, with the letters after their names, will carry more weight with the insurance company than yours. If they can illustrate that the superior BG control of the Libre supports your particular medical condition, and you can show Anthem that they're covering unlimited finger sticks adding up to the same cost as the Libre, you have your best shot (no pun intended).

Others with ideas? Others who have fought the same fight?

 

[gerryyy]

Do you ask your doctor's nurse to write a letter for with the above mentioned points, giving her a basic outline to go by. Then the doctor could sign that?

 

[hooverbw]

My Endo's office did try to submit the prescription and they were told I needed to be on Insulin in order to be covered for the sensors. The nurse said there was nothing more they could do for the insurance pre-approval. I will be sending a letter showing insurance that my 8 scans per day using a Freestyle Libre 2 is a lot cheaper than buying a new reader and the 200+ test strips that would match how much I am checking my BG right now using the sensors.

 

[itissteve]

Do you ask your doctor's nurse to write a letter for with the above mentioned points, giving her a basic outline to go by. Then the doctor could sign that?

My experience is that the doctor sees such letters right before he/she signs them, so, yeah. "I am contesting my insurer's denial and would like Dr. Kildare's recommendation that the denial be overruled. I'll need a letter stating X, Y, Z, please."

 

[itissteve]

I will be sending a letter showing insurance that my 8 scans per day using a Freestyle Libre 2 is a lot cheaper than buying a new reader and the 200+ test strips that would match how much I am checking my BG right now using the sensors.

I suspect their response will include the argument that as a T2 "You don't need to check your BG so often." Of course, we here agree on frequent testing. But I think you'll have to demonstrate to Anthem that testing so often gives you actionable information you can't get another way and that makes a real difference in your health. If you haven't already, you might submit receipts (or mock orders) from Anthem-covered pharmacies that show the cost is similar. You might also check if Anthem will treat the CGM as "Tier 2" or some level where they cover only a portion of the costs. Better than nothing, right?

But if all else fails, though it's not the preferred option, if you really prefer the CGM maybe you can cover the costs yourself. When I was diagnosed my clinic offered me a meter and -- what? -- 30 strips a month for testing. I already knew I wanted to do much more testing than that. So I declined their "free" meter and strips and on my own bought a decent meter that used cheaper strips (25 cents apiece in quantities like 200) and did my thing. My insurance has yet to buy me a meter or strips.

I figure diabetes has its costs. I'd rather spend the money on strips to test as I want and not get by on their free meter and just once test a day only to find that manage my diabetes in such a limited way later required me to spend money on stuff like diabetics hosiery and a cane. I realize that's not an option for everyone but if you've been covering the cost of the CGM for a couple of years, maybe it is for you.

 

[hooverbw]

I suspect their response will include the argument that as a T2 "You don't need to check your BG so often." Of course, we here agree on frequent testing. But I think you'll have to demonstrate to Anthem that testing so often gives you actionable information you can't get another way and that makes a real difference in your health. If you haven't already, you might submit receipts (or mock orders) from Anthem-covered pharmacies that show the cost is similar. You might also check if Anthem will treat the CGM as "Tier 2" or some level where they cover only a portion of the costs. Better than nothing, right?

But if all else fails, though it's not the preferred option, if you really prefer the CGM maybe you can cover the costs yourself. When I was diagnosed my clinic offered me a meter and -- what? -- 30 strips a month for testing. I already knew I wanted to do much more testing than that. So I declined their "free" meter and strips and on my own bought a decent meter that used cheaper strips (25 cents apiece in quantities like 200) and did my thing. My insurance has yet to buy me a meter or strips.

I figure diabetes has its costs. I'd rather spend the money on strips to test as I want and not get by on their free meter and just once test a day only to find that manage my diabetes in such a limited way later required me to spend money on stuff like diabetics hosiery and a cane. I realize that's not an option for everyone but if you've been covering the cost of the CGM for a couple of years, maybe it is for you.

I am working on a cost comparison for the appeal right now. I have been covering the cost of the sensors out of pocket for well over a year now. It is a small cost compared to the entire household prescription costs. And as a backup I buy the Prime meter and strips from Walmart out of pocket. I don't think I have asked insurance to cover my supplies for 6+ years. I have to meet my deductible ($6600) before they will even cover anything prescription-wise.

 

[itissteve]

That is one heck of a deductible, though...

 

[LindaPat]

Hello all.

I have been using the Freestyle Libre sensor for almost 2 years now and it has been wonderful. I have been able to control my BG better and my A1c shows that. So now I actually got in with an Endocrinologist for the first time in 13 years and she has encouraged me to continue using the sensor.

Here comes the situation and the question. I have been paying out of pocket the entire time for the sensors, my insurance out-of-pocket maximum is met for the year and I would love it if insurance would finally pay for the sensors. When we submitted the request to insurance (Anthem) they said it was denied because I have to show a history of not being able to control my A1c in order to qualify. Unlimited finger sticks is perfectly fine, but something that works better with a very similar cost is denied. Having the sensors are what has enabled me to control my A1c (6.4 at last visit) up to this point. At my worst I reached 10+.

Does anyone have any tips/tricks to get insurance to start covering something that I have been using already for 2 years? Thanks.

I've had a similar situation - they would support it for T1 diabetics, not T2. My doctor was adamant that the Kaiser pharmacy wouldn't fill the Rx. So, I asked for an Rx that I could take to an outside pharmacy. Figured I would end up paying for it out of pocket at full cost and was ok with that. So, off I go with Rx in hand to the local pharmacy - who fill the Rx and give my my health insurance discount....??? Cut the cost in half. I asked "are you sure" - they checked and said yep, your insurance covers this amount. So, I went with it. Maybe it can work for you....

 

[itissteve]

LindaPat's experience makes me wonder if some of those on-line PBMs (Pharmacy Benefit Managers) like GoodRx or Blink would be useful here. Free to "join" (use) and their Web sites make it easy to look up your stuff (though checking just now on Blink's yielded nothing for Freestyle or Libre).

 

[hooverbw]

LindaPat's experience makes me wonder if some of those on-line PBMs (Pharmacy Benefit Managers) like GoodRx or Blink would be useful here. Free to "join" (use) and their Web sites make it easy to look up your stuff (though checking just now on Blink's yielded nothing for Freestyle or Libre).

I have already checked with GoodRx and I am a member of the Kroger Savings Club (GoodRx I think). This is how we get our $2300 of medicine for only about $300 a month already. The Libre sensors aren't covered by any plan that I have found yet. And since I reached out-of-pocket maximum for insurance for the year I thought I would use it to help get the sensors. Guess I didn't expect the difficult process.

 

[itissteve]

Guess I didn't expect the difficult process.

Maybe I've been lucky but I've been happy with the way appeals of medical rulings have gone in my favor (though none to date have been diabetes-related). Appeals, however, require the requestor to speak the language the denier understands -- usually money. If it's no more money to get what you want than it is for them to maintain their policies, unless there's just a hidebound bureaucrat hiding in the wings, you get it (or at least what they can provide of it). Most big organizations, though, are unlikely to be moved by something that can't be measured discretely. They lack the flexibility to customize their approach and some of them are terrified by precedent. 😕

 

[Lee_Bo]

That’s odd. When I look on GoodRX and SingleCare I do see the sensors available for a little more than what I’m paying for them now (BCBS).

Maybe it depends on where you are?

Sent from my iPhone using Tapatalk

 

[itissteve]

That’s odd. When I look on GoodRX and SingleCare I do see the sensors available for a little more than what I’m paying for them now (BCBS).

Maybe it depends on where you are?

Maybe. Minnesota; didn't check SingleCare. Prices don't seem like screamin' deals but it could be an option for some. Thanks for checking that out.

 

[Lee_Bo]

Maybe. Minnesota; didn't check SingleCare. Prices don't seem like screamin' deals but it could be an option for some. Thanks for checking that out.

No problem. When I changed jobs I looked into GRX and SC as alternatives until my new company’s insurance kicked in. I still use them for comparison.


Sent from my iPhone using Tapatalk