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From Barnegat, New Jersey, USA:

My daughter was recently diagnosed with type 1 diabetes. She is 11 years old and takes insulin four times a day. We paid for insulin through my prescription plan and all supplies were supplied from my medical insurance. Then, I found out that my medical insurance also covers the insulin. When I called them about receiving the insulin from them, they told me if I have a prescription plan I would have to go by this way. They said that New Jersey has a mandate that health insurers have to supply insulin if the person receiving it does not have a prescription plan. Can you help in defining this law? Is it true that I must use my prescription plan or is my health insurance just trying to get out of supplying this medication?


I see that you receive your health insurance benefits through your employer's group health policy. While you look at the coverage you receive as one comprehensive program, it is actually two or three different insurance policies (or contracts if the benefit program is partly or fully self-funded by the employer) woven together in a coordinated comprehensive benefit package. One contract or policy is responsible for providing major medical benefits (doctor's office visits, ancillary services like laboratory tests and radiology provided outside of a hospitalization, and durable medical supplies like strips and monitors). Another policy or contract provides access to prescription drugs and other approved non-prescription pharmacy items. Generally, injectable drugs like insulin are covered under the prescription drug coverage, even if you do not need a prescription to purchase the item. The New Jersey law setting coverage requirements for diabetes education, equipment and supplies is satisfied so long as a comprehensive policy or group benefit program provides coverage for the specified services or items. The law does not look behind the curtain to see what pieces of the coverage are covered by what parts of a coordinated health benefit program.


Original posting 7 Mar 2006
Posted to Insurance/Costs


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Last Updated: Tuesday April 06, 2010 15:10:06
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