In December, 2012, I was told by my insurance company , Medical Mutual, that they will no longer be covering Apidra, but that all I need to do is get a basic prior authorization from my doctor and all would be ok. Wow, was that ever an understatement!
I had a little less than 1 bottle left over at the end of the year, so I went to try to get a refill around January 5. No go. I went to my Endo to ask for a prior authorization. The PA who handles such requests was not there and the woman who took her place seemed to not understand what I meant. I even had a rejection printout from the pharmacy and the number to call my insurance company to make the authorization, which I confirmed with a presentation of my insurance card. She said she would check it out and get back to me. The next week, I would soon be running out of Apidra, so I went back to the doctor's office, as they had called me in after my numerous phone queries to them. I had contacted my insurance carrier, Medical Mutual, who said that Apidra was not longer on their formulary and that they were not sure if a prior authorization would help. I called the insurance company the next day; and the customer service woman who answered their phone this time said that they would cover it if my Dr. Sent in a prior auth.
The next morning, I went back to the doctor's office and got a no copay card from the PA and I tried to explain to her that that would not help me. She said that the Apidra rep told her it would take the place of a prior auth. ARgghh!!! I felt like I was talking to a brick. It was late in the day; I came back a third time, two days later, and reiterated my predicament to the receptionist, and received two bottles of Humalog "to use while we work this out." She did say that the new PA was not familiar with prior auths. and that I would have to talk to "C", the more experienced NP (whom I have worked with in the past, as she has been with this practice, like me for years) to get the prior auth. the receptionist said I had been to the doctor's office so many times (Phone calls do not work with them, and there is no way to e-mail the office., just fax or snail mail), that she would get she would ask "C" to do it.
Meanwhile, I have been in contact with Sanofi-Aventis, the Apidra manufacturer, and they told me that there was a coding error with Apidra where it was inadvertently not covered for some Medicare recipients, and many insurance companies followed suit and refused to cover it in 2013. Supposedly, this discrepancy will be taken care of in the next few weeks.
I really like Apidra and do not want to continue using the Humalog I have been given. The tail is too long and I cannot get the quick corrections that I am accustomed to. Plus, I am a pre-65 retiree and my Humalog, before my high yearly deductible, would be 143 a bottle and I use about 2 bottles a month Pretty pricey!!!I could get, after the No copay card is used, the Apidra at $60 for the two bottles as Sanofi -Aventis would take care of the $50 copay per bottle with the savings card. Quite a savings, but I believe I will be forced to go to Humalog, unless my doctor’s come up with the info I need to go back to Apidra.
Yesterday, (Sunday 2/11) I went to the CVS pharmacy I usually get my prescription filled that has the Apidra script on file. We ran the script again and it was rejected. The pharmacist said to do whatever I need to do to get a prior auth. from my doctor.
I really like my endo, but his office is understaffed and many are not trained well. Will I have to write the pre-auth and just let my doc sign it? What do I have to do to prove that I get better control with the insulin that I have used for the past 8 years?
I have only been on Humalog for about 3 weeks SO FAR, in 2013, but I am seeing a difference. I have to wait 3-4 hours for a full correction to take, unless I almost double the correction suggested by the bolus wizard. This throws my day off and makes me want to "rage bolus" to get a high down quickly so I can go about eating and taking part in a regular day. Have had really crappy blood sugar swings from overbolussing to avoid 3-4 hours of highs. OF COURSE, I get a resultant, reactive low, and many times a rebound high. Vicious cycle. I just prefer a low to a high, any day. (Like 314 to 37 in the space of 7 hours. Not fun.
I had some roller coaster highs when was on Apidra, some due to user error, but I did not find I had to double the correction factor with Apidra.
I want to keep using it, but I cannot readily afford it straight out of pocket, neither can I do the Humalog easily. Will probably take me another 5 months to meet the deductible. I did not pay for Apidra at all last year, even prior to meeting my deductible. It went through with no-copay and no price as covered by my insurance. Now I am being told they do not cover it at all. BIG CHANGE
Should I just go and sit at my doctor’s office and demand a prior auth? What info should I ask from my insurance company prior to going for my "sit-in"? I do not plan to be evil and nasty, that is not my style. I will be sweet and persistent and will sit there for several hours, or all day if I have to.
Has anyone run into similar Apidra and doctor office problems? Perhaps those of you who work for or are familiar with insurance companies may be able to help.
Thanks for taking the time to read this, and in advance for your thoughtful consideration. TuFamily, mi familia
I am pretty sure that Medicare (CMS) has not fixed this yet. There is something on the Apidra.com web site.
IMHO, Apidra is worth fighting for if it works for you. I just got my latest A1c, a 7.0. The last 2 before that were 7.1 and 7.0. Before that I was on Humalog and my A1c's were 7.9 to 8.2. That says nothing against Humalog but with my lifestyle and my body Apidra is better for me.
Hi Brunetta. I have the same problem -- my insurance company won't help to cover my Apidra, Levemir, or my injectable B12. Just the three things that keep me alive! I'm going to go to my pharmacy today to see if my doctor was able to convince them that I need the insulins. The B12 will have to be out-of-pocket, but it's not expensive. Good luck to us both...
Hi Brunetta, here's an update: as of this afternoon, my doctor was able to get me an exception to both Apidra and Levemir; that is, the insurance company will make a co-pay on them both. These exceptions will last for one year. I hope you're getting a good resolution for your insurance problems.
I'm sorry to hear of this difficulty. It really sounds like presenting your doctor with drafted letter of prior authorization/medical necessity may be the easiest thing to do. If you know how to write it it should skip past some of the difficulty. The other suggestion I have, I know you might not like it is intramuscular injections. I correct by injecting right into my quad perpendicular. I have almost no body fat on my leg and it makes my humalog really act fast. Just a thought.
BSC, Brian the thing is I do Not know how to write it. I just talked to the phone rep of my insurance company's prescription carrier, Express Scripts, and she told me no formal written letter was needed; that only a phone call and questions answered by the doc's office was needed. I CALLED THE DR.'S OFFICE AND I left a detailed phone message with the prior auth 1-800 number , ( 4th time I have left it with them, 3 times on paper with a personal messsge) I am putting on clothes, now, to go there, and watch them do it. I am taking my lunch and a book to read. Does any one think that the prior auth will work? BTW the pharmacist at CVS told me that she did have patients whose insurances were still covering Apidra in 2013. But I bet they were not at or near retirement age, as I am at 58. Thanks for the support, all. Off to see what happens when I make my appearance.
Yup, sometimes you just have to get in their face, be a squeaky wheel and make sure it is done right. I hope you enjoy your book and I hope they don't enjoy your being there. My last adventure was having my pharmacy lose my test strip prescription, having to have my doctor resend it, then having the pharmacy mess it up giving me half and then being told that I could have it fixed, but I would still have to pay my co-pay again for the second half.
Also note... sometimes the providers (docs and pharma companies) and the insurance companies play "chicken" with us.
e.g. they will remove a drug from the formulary, and wait for complaints to pour in, and then put it back in the formulary. Or an insurance company will remove a doctor's office (in many cases, entire practices with multiple docs) from the preferred provider list, while negotiating over rates with that office.
In many cases the actual coverage never actually lapses, and I think either the insurance company or the docs office/pharma company was just seeing if they could use us (the insured) as a bargaining chip. My household budget wouldn't be dented too much if I had to pay for a single doctor's visit, or a single prescription, out of pocket, but others are much closer to the brink.
I absolutely believe that there have been cases like you descibe. In this case though it is human error.
CMS, the people who create codes, made a clerical error which resulted in Apidra being dropped from Medicare/Medicaid. Some insurance companies followed suit. CMS has said that they will fix the error (but the only update the codes periodically).
Those games of chicken are more likely with the very popular drugs or when the drug is the only one in its class. Apidra doesn't fit that profile.
I know this doesn't help Brunetta, I am trying to figure out if the prior authorization can be any letter or has to be entered on her insurance company's form. Does anyone know?
I am willing to believe that it was initially just a human error. But the way the error propogates between insurance providers and to the checkout at the pharmacy, makes me a little cynical that the insurance companies actually want to fix it.
They seem to be doing everything they can to make it look at first glance, as if it's not covered, and only the persistent will find out differently. i.e. it looks like they are using the mistake as an opportunity to play chicken.
I was allowed one month's worth of Apidra and Levemir in January, and told by mail that was the end of their coverage. They do cover Novolog (too slow for me) and Lantus (which gives me brain fog and a constant headache).
Hola Brunetta, If I were you I would leave it alone, use the Humalog, and walk off the tail. I know that it seems counter-intuitive, but at this point the stress will damage you more than anything. To me all the trouble and stress wouldn't be worth it. What do you think? See if you can get some fast acting if it is on your new forumulary?