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Question:

From Novi, Michigan, USA:

My wife's prescription carrier is changing to a new provider. She just got a booklet describing which drugs are covered with a copay and which ones we will have to pay the entire prescription amount. Every type of insulin we get is NOT covered, neither is glucagon, syringes, test strips, or lancets. It is almost as if they decided to not cover anything diabetes related.

Answer:

Health plans have the right to change benefits or providers from time to time. In this case, the plan elects to provide its coverage for diabetes equipment and supplies through its prescription portion of the plan. Like many plans, it has hired a prescription benefit manager (PBM) to manage or administer its prescription drug program. PBMs save their plans money by limiting the choice of prescription or plan items. Most plans limit their selection to one item per class of drug type. Michigan does have a state law requiring most health insurance plans to cover a minimum level of diabetes treatment items and supplies. However, many plans are not subject to the minimum requirements established to protect Michigan residents. Self-insured or ERISA plans, as well as plans for many public employees, are not covered by the law. As far as the extent of benefits your wife is entitled to, I cannot determine from your correspondence. I recommend that you examine the plan benefit summary for the plan to try to learn the type of plan. You can also contact the Michigan State Insurance Department for assistance. Their telephone number is likely in the blue pages of your telephone book.

DSH

DTQ-20040108095011
Original posting 21 Feb 2004
Posted to Insurance/Costs

  
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Last Updated: Tuesday April 06, 2010 15:09:54
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