My friend was diagnosed with type�2 diabetes two months ago, and his doctor prescribed Glucotrol and Actos with good results. However, his insurance company is refusing to cover these medications, saying that they are “unnecessary”, “experimental”, etc. even though these medications are listed as “covered” in the policy.

My friend is now so despondent and depressed that he has decided to forego all medication and hopes to have an emergency situation where the insurance company will cover it. He cannot afford to pay for these medications himself, and has paid for this particular health insurance coverage for over 10 years with no prior claims.

I don’t understand why an insurance company would deny coverage for medications that are working, especially if they are listed as “covered” in the policy. Please give some guidance on what course of action to take.

The experience you describe is, sadly, not an uncommon one for many people with diabetes and other chronic diseases. New medicines are more costly than the old ones, even though they are more effective in keeping people well. I have the following suggestions for your friend:

Talk this over with the physician. It might be that a letter from him/her will be required for “prior authorization” for newer medicines. The co-pay may be a bit higher, but still considerably less than buying them himself.
Ask the physician for samples until the time that the drugs are covered.
Have your friend ask his physician how he might apply for medicines directly from the pharmaceutical company. Some will provide medicines under “compassionate” use if people are unable to buy them themselves.

I agree that it is not right for insurance companies to withhold quality medicines, but, due to increased costs, this is a common practice. If we don’t continue to fight for these new drugs, the insurance companies will win, and the people needing the drugs will lose. It is also going to be necessary for all of us to get used to paying a larger co-pay for these more expensive drugs.

KS

[Editor’s comment: These medications are not experimental. If they are listed in insurance company formulary and were prescribed, they should be covered. Typically such claims are reviewed by individuals who are merely following some sort of protocol, and my guess is that they have one which states the Actos [pioglitazone] is covered only after a trial on a standard sulfonylurea alone (which Glucotrol is).

I agree with Kris that your friend should ask for samples and have his physician write a letter of medical necessity. He should also request a review by the medical director for the health plan. Usually, insurance companies will capitulate under such pressure.

Your friend might also contact the local chapter of the American Diabetes Association for additional advice and assistance with this matter.

SS]