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My daughter started on Omnipod last winter.
1) Our insurance, United Health Care + Medco Pharmacy considers Freestyle strips as a Level 3 drug. Level 3 drugs are $70/mo copay while level 1 (eg. one touch ultra) are $10/mo, but they need too much blood for my daughters liking and her sensitive skin.
2) Abbott Labs has a co-pay assistance program (called Promise) which reimburses upto $50/mo of copay, but United Health Care / Medco do not have the billing system in place to work with Abbott Labs. Ironically, all the major retail pharmacies can work with Abbott labs.
3) UHC/Medco cover these strips ONLY through their mail order . So our copay is $210/3-mo for test strips alone. And they will not let us fill this prescription at Retail pharmacies even for the same $70/mo copay which would have allowed us to get Abbott labs to cover $50 of the copay.
At my last call to UHC I told them that Freestyle strips are integrated with the Omnipod and asked them why they would not let us buy them at Retail phramacy for the same $70/mo copay. She advised me to appeal this to try becoming eligible to buy them at a Retail Pharmacy.
Has anyone experienced something similar and appealed it successfully? Can you please share how you did it and what worked/did not work?
No idea how to do that. I experienced the same thing about a year ago with my strips moving levels. My insulin cost dropped, but my strips went from around $10 to $50 now. So irritating.....Good luck!
I spoke to a rep who came to my place of employment, explaining that the strips are not as fungible as they think they are. They seemed to think that I had grounds for appeal, but I just gave up and used the mail-order service. I would think that explaining that the insulin pump system you use relies on the Freestyle strips and cannot be used with strips that they would prefer you buy, and that is the only reason you are tied to these particular strips, might move them to allow you to work with the pharmacy instead of the mail order company, in light of the financial burden they are placing on you by forcing you to go through Medco.
I imagine that their counter would be something like: "Well, you can do your blood testing on another device that uses the Level 1 strip, and then put the values into your PDM." This is, of course, kind of stupid, but they have a financial incentive to get you to use the Level 1 strips. I think you just have to have your counterargument: "So you are advising me to carry an additional device, making my testing less convenient and my insulin delivery more prone to error, even though I am willing to pay you the same amount per strip as I would doing mail order? Interesting..."
I found that if you have your insurance thru an employer getting their Human Resources people involved in the appeal can be effective. My appeals (on my own) never worked. Also, the Promise program accepts a receipt from the Cigna mail order insurance pharmacy. Or have I not understood the issue correctly? Good luck with UHC; my experience with them was draining-to put it mildly.
If you call the Freestyle Promise program they will send you a form for getting the $50 rebate from mail order pharmacy...as you send in each one, they will send you a form for the next along with a check.
We are in the same boat. We appealed, but had no luck. But we do still use the Promise program, we get the $50 back every 3 months instead of every month, though. It's not much, but it helps. (we have two of us on Omnipod) I was very frustrated when we found this out, but then I talk to people whose insurance won't cover Omnipod at all, and I am thankful.
We appealed this - not to get to buy them at retail, but to qualify for the cheaper co-pay. I argued that the tiered system (ours are called tiers instead of levels) only worked for people who could make a choice, which are generally type 2 patients who don't use a pump - the majority of the diabetes market. Because my son is a type 1 patient whose pump only accepts one type of strip, I was able to argue that his strips could fall under the cheaper tier - and they have allowed it. I have to re-appeal every year, but it's worth the cheaper co-pay for us! I just make phone calls and explain my story and that I understand the tiers, but that it's not fair for those of us who don't have a choice. I have no idea why it's worked, but it has.
My strips weren't covered at all through my insurance. When I explained they were integrated, and if the pod was covered, shouldn't the strips be? I was told (by insurance) my Dr. just had to fill out a form ( I can't remember off the top of my head what it was called.) Bingo, worked.
A year later, my dr's office called me and told me the pharmacy called them and said the strips weren't covered, I had to switch to one touch. Come to the dr's office and we'll get you a meter, scrip...etc. After a phone call to insurance and trip to pharmacy, I found out what really happened. The pharmacy called the dr's office twice, and told them the form from the year before was expired and needed to be submitted again. The pharmacy was frustrated that the dr's office wasn't re-submitting, and was just changing the scrip. I have a great pharmacist who is Type I, so it was good having the ally! I still can't believe how lazy the dr was trying to be!
I experienced the same issue last year. When I started on Omnipod, UHC covered it for 3 months to be refilled at the retail pharmacy. Later they stopped covering it and I went through the appeals process to have it covered. The doctor sent something to them in writing but they refused to cover it. I finally got very frustrated and switched to One Touch. I hope you have a better outcome.