From Pittsburgh, Pennsylvania, USA:
My 13-year-old son has been on an insulin pump for just over a year. It has always been the recommendation of his doctor and nurse practitioner that he test up to 10 times per day. He is active in sports (baseball) and starting puberty. I feel it is important that he test often to manage his blood glucose levels. Our insurance company will only cover enough test strips to test three times per day. Do you feel three daily blood glucose checks are ever adequate for proper management of type 1 diabetes? They say they would cover more strips if he used a different brand of meter, however, that is not the meter which is compatible with his pump. Should I have reason to believe that the insurance company is unfairly promoting a certain meter brand by denying my son the supplies he needs to care properly for his diabetes as suggested by his medical team? Have you heard of this happening to other families?
Health plans can establish reasonable coverage limitations on usage of diabetes supplies. This is an issue that we have discussed in previous questions frequently. In addition, many health plans are creating arrangements with preferred pharmaceutical and DME manufacturers; these are called exclusive formularies. Generally, insureds are required to pay higher copays or cover the cost of items and medicines/strips not on the plan's formulary. As you are finding, your health plan contract probably provides for higher copayments or coinsurance requirements for drugs and items not on their formulary. You are entitled to file a written appeal to the decision of the plan concerning the limits on the use of strips for testing. This appeal should contain documentation from your physician of the medical necessity of your child’s use of that brand of meter and the amount of testing required. You must follow the timelines and requirements established by the plan to proceed with your appeal. Unfortunately, in your description you did not mention if your plan is self-administered/self-insured. If so, these plans are literally unregulated and patients are left to beg and plead for coverage when the plan administrator denies a claim. Keep in mind that if you are given a choice of health plans, you might want to change at the next open enrollment period to a plan that covers the brand of meter that you prefer.
Original posting 9 May 2007
Posted to Insurance/Costs
Last Updated: Tuesday April 06, 2010 15:10:11
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