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October 16, 2006

Insurance/Costs

Question from Western Springs, Illinois, USA:

My daughter tried the Freestyle Flash meter at the CWD pumping conference and loved it. I obtained a prescription for the testing strips, but was told my prescription insurance coverage (Caremark) does not cover Freestyle supplies. What steps should I take to change this?

Answer:

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. The 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. This appeal should contain documentation from your physician of the medical necessity of your daughter�s use of that brand of meter. 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.

DSH