Yes, Insulin IS a medical necessity

6 03 2011

I have been on Humolog since it was released in the US in 1996. It is not working like it used to, so I’ve decided to give Apidra a try. I tried it last summer at a diabetes camp I was visiting —one pump full to be exact. It worked great. If nothing else, any change in my diabetes routine forces me to pay really close attention to how it affects my body, exercise, food, etc. which helps my blood sugar control.

Last Thursday, my endocrinologist and I talked about the change which she agreed with, so she wrote the prescription. A usual she gave me a physical copy and sent one to my pharmacy. I don’t know how this pharmacy stays in business since about 1 in 3 prescriptions get lost, so I always call to check in.

After 25 minutes of them telling me they do not know if they have my prescription (yes, they told me they don’t know), and 3 phone reps later, I spoke to someone with half a brain— just half mind you. This rep told me that while he still cannot tell me if they have the prescription or not, they can’t fill it.

My natural reaction, “Why?”

“Sir, you need a letter of medical necessity.”

To which I reply, “I thought a prescription WAS a letter of medical necessity.”

I knew I wasn’t going to get much further with this without some help, so I asked where I should have the Dr. send the letter. He gave me a phone number. “Is this the fax number?”

“No. Have your doctor call here to find out what to do.”

Very calmly, I asked if he thought someone who spent
a)   over a decade studying medicine
b)   nearly 2 decades treating diabetes
had time to waste on the phone to get the same result as just writing a prescription in the first place.

He responded plainly; “No.” and hung up.

Look for the exciting conclusion to this story next week! (Well, I hope this is resolved by next week though, I’m quite skeptical).

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11 responses

6 03 2011
Salrac

Not that I’m making excuses for your pharmacy, but a letter of Medical Necessity and a written prescription are two entirely different things. A written prescription is just that, a prescription naming the drug prescribed, strength, instructions and the length of need up to a year depending on type of RX, and MD’s prescribing information.

A letter of medical necessity is for the insurance company and is to give them reasons as to why they should cover it for your condition. It goes into greater depth then a prescription, it should give the diagnosis and reasons why Apidra is better then Humalog for your specific condition.

Also, I don’t know what state you live in…but in most, Pharmacists are now Doctors, AKA PharmD’s , They have 4 years of college, 2 years of pharmacy school and 2 years of rotations – including a medical rotation in a hospital. They have a brain….I would suggest if your using mail order – don’t – that’s where the bottom of the class goes. Or switching to a pharmacy that has a pharmacist younger than 35.

And I am not a pharmacist – but an insurance specialist – for 17 pharmacies. If you have such a low opinion of your pharmacy, you really need to change. Your pharmacy should be a 2nd source of helpful information and be more knowledgeable about your medications then your physician. Did you know that Humalog and Novalog are interchangeable, but you may have entirely different results with Novolog also – You may want to consider Novolog if Humolog isn’t working.

6 03 2011
Joan

I think since OBAMA and the government changed all the medical rules that so many people are having trouble getting there meds. I know here in Vt I am. My dr. blames the pharmacy and vice versa. I hope that the Drs. and pharmacies can get together and straighten things out. I have spent many hours on the phone with both partys, drs. and pharmacies. Good Luck to all.

6 03 2011
yes, I AM an "ic"

I guarantee you, going to college does NOT mean you have a brain. Try a school with an “open enrollment policy” and you’ll understand what a drive-through degree is. I am not an insurance specialist for a pharmacy, I’m an insurance agent, and any type of insulin is ALWAYS a medical necessity. It’s not like viagra, or even heart medication that you can skip or try diet and exercise. Insulin is needed DAILY to live. Any health insurance company that doesn’t know that shouldn’t be in business (oh but just try filling out a personal insurance policy application and mentioning you take Apidra – they won’t request an explanation before making a decision). A prescription is necessary to prove the person buying the insulin does in fact need it, but if the doctor prescribes it, it’s the kind of medication that is NEEDED. It qualifies as a life support “device” and it cannot be purchased with or without insurance unless it is medically necessary. The only reason to require a letter of medical necessity for insulin is if there is a generic brand and you want the name brand; but there is no generic insulin. No two insulins are “interchangeable” because of the fact that you will likely react differently to all of them, and whatever the doctor prescribes it’s because that’s what will do the best job SAVING YOUR LIFE. Neither is insulin the type of drug prescribed for “off label” uses. It does one thing, and the recombinant form does the same thing the natural one does. Prescription insulin replaces a vital hormone that type one diabetics simply don’t produce; you really need an explanation as to why it’s necessary? How about we remove your pancreas for a couple weeks and see how you feel? (don’t worry, we’ll keep it on ice. Lucky you…..)

And one glaring red flag: why didn’t anyone mention this when the doctor sent the prescription over? or any of the previous times he (the author) called?

As for changing pharmacies, that’s not always possible. Some private healthcare facilities require that you use their pharmacy or one they are contracted with in order to cover medications.

Now, I realize the first thing you said is that you’re not making excuses for the pharmacy, but unfortunately you continued on by doing exactly that. Not to mention a couple other things you said quite frankly just make me want to slap you.

6 03 2011
di

I don’t think resorting to violence is going to help. Dealing with this disease is frustrating enough without all of us going at each others’ throats. Be nice please.

7 03 2011
Joan

I agree Di it is enough dealing with diabetes. I have been-diabetic since 9 and am now 64 on pump for 1&1/2 years. I am in very good shape for having this for so many years. Frustrating is a very good word to describe the disease and all we go through. Some days good others not so good. I do not want to argue with anyone. Have a good day all. We are going through a blizzard right now so need to get out as soon as possible and start shoveling! Another good day in Vermont LOL!!!

6 03 2011
Carol N

I am so glad that I an not the only one with pharmacy problems. We finally fired our pharmacy and we are trying another after month after month they had some problem filling our sons prescriptions. It is so frustrating that they would tell me things I knew were not true – they don’t make syringes with half unit markings when I knew they did because I had some. Most of the time I had to look up the NDC#’s and on more than one occasion they shorted me medication. The excuse they would give when they shorted me strips etc is that they are not used to dealing with people that have type 1 and people with type 2 get fewer strips. I guess it was to much to expect them to actually read that the prescription was for 300 strips.
Now that we have changed pharmacies things have been going a lot smoother.

6 03 2011
Jill

In the previous posts I have noticed a lot of blame and talk about the pharmacists, pharmacies, doctors, and even our president, but I didn’t see a whole lot said about the real culprit in the issue, the INSURANCE COMPANIES!
It is your insurance company that requires a ‘letter of medical necessity’ in addition to a prescription for an RX item and this is just a way they try to get around paying for more expensive drugs or therapies. Usually, but not always, these items are newer to the market and so the insurance company will label the as ‘investigational’ or not medically necessary’ and then deny coverage. And it doesn’t matter what the doctor says is medically necessary because in our country and with the current health care payer system the Insurance Companies have the final word, and believe me their #1 interest in NOT YOU OR YOUR DIABETES! It is cutting cost, plain and simple. Which is something President Obama tried to correct in his original proposals but were not passed to be included in the healthcare reform bill.
I know with my Blue Cross plan that Apidra is not covered, even though my doctor has recommended the change from humalog, and is considered to be not of medical necessity since they claim it is no different than humalog. And how do they know or come to these conclusions is what I would like to know!

6 03 2011
Jill

In addition, I would like to say that is has ALWAYS been my experience it is the insurance company to blame and with over 20 years of experience with dozens of companies and policies I feel I speak from experience. However, you will never be able to get an educated answer or explanation from them. Most the time when it comes to diabetes it is like speaking a foreign language with them. But I also wonder about the credibility of your doctor because if he/she is on the absolute up and up then they should have been able to explain this to you when writing the prescription because it has been an issue for many diabetics since it became FDA approved. I would call your doctor on Monday morning explain the situation and ask that they fax the letter to the insurance ASAP so that they can then determine if they will cover it or not. The sooner you know the better.

On a side not I am looking forward to calling my insurance in the morning to give them a solid and agitated piece of my mind. I have been using a continuous glucose monitor and sensors with my pump for 2 years now and had them approved and covered under 2 previous plans. I was starting a new policy in OCT. odf 2010 and so in Sept. I began calling the company and had my doctor submit all the necessary letters of medical necessity for all of my pump and sensor supplies so that there would be no delays once it came time to order them. It took dozens of calls to the insurance to get them to understand what I wanted to know and figure. Eventually I placed an order through the supply company who eventually called to tell me my insurance was not approving the items yet and so the order would be delayed. When I called the insurance they of course, again, assured me there should be no issue and could not understand what I was saying so I had them do a 3 wasy call with me and the supplier and they instructed the supplier to ship the supplies, which are very expensive and non-refundable, because they were in fact covered and no pre-authorization was required. I thought this was odd but hey she is the insurance representative and I heard the supplier describe to her the order and her authorize. So I receive the items the claim goes throguh and of course is denied. Why? Because the items are considered ‘investigational’ and so even with the RX and letter of medical necessity my sensors are in fact denied! My blood pressure boils just thinking about it! So now I will be getting an expensive bill and responsible for the entire total, even though the supplier would have never sent and I would never have consented to purchasing orders had the moron from the insurance been able to do her job accurately!!!!!!!!

6 03 2011
Salrac

Again…slap away. I stand by what I said. You injected a lot into what said, such as Insulin is not a necessity, that I never said. As for yanking my pancreas, I would gladly do it in a heartbeat if I could insert it in my child.

I actually thought your pharmacy WAS lame…but now I think you are.

I see the whole problem here…your physician is a God and can do no wrong. You’re an Insurance Agent, so you obviously work for the Insurance company, so they can’t be doing anything wrong. So lets blame EVERYTHING on the pharmacy because they’re stuck in the middle getting a lot of arrogance from you who seems to sells insurance, but knows nothing about actual procedures of how the health insurance claims process works.

As the mother of a child with Type 1, if she ever gets an “entitled attitude because my pancreas doesn’t work” like yours, I’d be incredibly embarrassed. She’s allowed to joke about it – but never to use it anger against other people. What a woe is me cop out.

7 03 2011
Salrac

I apologize for assuming that “yes, I AM an “ic” was the blog author.

I’m just extremely happy to find out Broken Pancreas didn’t not write back with such hostility.

As a parent of CWD, a JDRF mentor, and volunteer with various ADA, DRI & JDRF activities – I have been able to help 100’s of people on how to save money at their pharmacy, how to have a different insulin or item authorized, how to get help with getting medications or supplies when you don’t have any insurance and other various pharmacy problems. My intention was not to start a war, but only to explain the difference between 2 documents and why the MD has to do the foot work.

But a pharmacy that repeatedly loses RX’s – that’s suspect – but many times it’s the clinic (if it’s a clinic in a large system) – they’ll have a central site server that sends them out sporadically. It can take up to 24 hours for a central site server to fax out a RX and many of the MD’s don’t realize that. So the pharmacies and clinics blame each other.

I would have the MD send E-Scripts instead of faxes, or continue to bring in written RX’s. If they are losing either of those, then I would report them to the state board of Pharmacy licensing.

6 03 2011
Joan

I blame a lot on layoffs. Not enough people to keep up with all the demands. I know my pharmacy is so busy every time I go there-everyone complaining about prescriptions not faxed in by drs. One fax machine for 7 drs. does not work! Many being left out or not sent at all. The office needs to hire someone just to fax in prescriptions-just my opinion. We can play blame game but just realize it will get worse before it gets better. Take care of yourselves and best wishs to all.

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