Who’s in charge- your doctor
or your insurance company?
These are strange times, when we have to think about insurance companies and medical suppliers like they’re our doctors.
No, they aren’t. But don’t tell the insurers and suppliers that tend to act this way.
Using strong-arm language like “not covered” and “preferred brand,” they try to force our hand. And then they take it to the next level by disregarding doctors’ decisions and ignoring prescriptions, weaponizing phrases like “therapeutically equivalent” and urging us to jeopardize our health with a treat-to- fail step-therapy regime before even considering what our doctors have already prescribed.
This is the world of Non-Medical Switching, where payers justify their decisions based on cost more than listening to the medical advice of our healthcare professionals.
I’ve experienced this many times, and it’s an issue my medical care team and I are always frustrated with. There are four examples that come to mind, from recent years:
CGM Type: That time at the start of a year with a new insurance company, when I was refilling a Dexcom CGM sensor order and the company told me that they would rather not approve this CGM because I happened to use a Medtronic insulin pump – and so, that brand of CGM would be a better fit for me. (Result: It took insistence with an insurance supervisor to make it clear my doc and I knew what was best, especially given I’d been on Dexcom for years).
Lantus to Tresiba: When the new basal insulin Tresiba came out from Novo, I studied a lot of the data and patient reported outcomes (PRO) that showed it might be better for me than Sanofi’s Lantus. In particular, the fact that Tresiba could last 42 hours rather than the 24 of Lantus, and I may not have to split my total basal dose into twice-a- day to see the most effectiveness. Their argument: That Lantus was “therapeutically equivalent” to Tresiba since they’re both basal insulins. And so before they’d cover Tresiba, I’d have to show Lantus didn’t work for 30 days, and then competing Levemir also didn’t work for 30 days. (Result: My doctor and I reiterated that I’d been on Lantus for months, and that this “step-therapy” had already been met – Lantus didn’t work as evidenced by my higher A1C and glycemic variability, and if my insurer described Lantus and Levemir as “therapecally equivalent then they couldn’t very well argue I’d have to waste another 30 days trying that insulin. We ‘won’ after firing off an appeal letter to the insurer).
Humalog to Novolog: Pretty much the same situation as above, but this time I decided that it wasn’t worth the fight to try for Humalog. I’d never actually tried Novolog before, and despite reports out there about insulin differences and allergies, there was no guarantee I’d experience that. (Result: So, I opted to switch to Novolog pens and in the end saw no difference from what I had while using the other brand. Of course, when looking at the actual cost breakdown on the Explanation of Benefits, there was hardly a difference in overall price tag between the two brands – even though I’d be paying a $40 difference in copays.)
Afrezza inhaled insulin: That time my doctor and I decided inhaled insulin would be the best treatment, instead of just injected insulin that wasn’t doing the job. We again had to hear about step-therapy, and interestingly despite my past use of Humalog and Novolog, my Afrezza still wasn’t initially approved. We wrote a letter contending that we had met the step-therapy, and that Afrezza was medically necessarily to prevent my severe hypos and glycemic variability. It took two rounds of letters, but we once again prevailed. (Here is my appeal letter).
Countless people who live with diabetes and so many other health conditions experience this type of short-sighted Non-Medical Switching every day.
My endocrinologist has told me stories of others experiencing this NMS, who simply don’t fight and accept whatever the preferred payer brand is. And that months later on a return office visit, my endo learns that they weren’t using the prescribed medication.
He has often wondered aloud, “Why bother having a medical license and even writing
prescriptions, when they’re denied and second-guessed 99% of the time?”
I’d also argue it’s criminal, in that it equates to practicing medicine without a license. The individuals making these decisions may not even have an M.D. behind their name. Sure, there’s probably a doctor on the letterhead somewhere, but it’s an actual nurse or even a lower health insurance employee actually approving or denying my insurance claim.
Of course, I’m lucky.
See, I know that payers are in this for cost. And I know that you don’t have to take “No” for an answer. Even when insurers, Pharmacy Benefit Managers, and third-party distributors try to force a change, that’s not the way it has to be. Patients have power and can fight back, sometimes with a little extra effort and at other times with more extensive appeals for coverage.
None of this is right and I fear it may get worse as this becomes more mainstream practice. I’m hopeful that national and state-specific advocacy and lobbying actions can move the needle, but in the meantime those of us on the patient and provider side are left dealing with these issues in the trenches.
What You Can Do to Help Stop Non-Medical Switching
Children with Diabetes (CwD) is a 501(c)(3) non-profit organization that provides education and support to individuals and families living with type 1 diabetes. The organization has recently established a website (www.MyMedsMyChoice.org) to gather basic information from all people with diabetes (or their caregivers) and healthcare professionals about their experiences with non-medical switching. The website links to two short surveys: Patient/Caregiver and Healthcare Professional.
The Diabetes Patient Advocacy Coalition (DPAC) supports this initiative and urges you to go to the website and complete the short Patient/Caregiver or Healthcare Professional survey. DPAC’s statement on non-medical switching can be found here.
Michael Hoskins is associate editor at DiabetesMine. Diagnosed with type 1 at age 5 back in 1984, Mike’s the son of a type 1 mom who was diagnosed at the same young age in 1958. He’s been an insulin pumper since his final year of college in 2001, graduating not only from two shots a day but also with a bachelor’s degree in journalism from Oakland University. A writer for most of his life, journalism has been a focus since middle school and has taken Mike to a variety of weekly, daily and specialty newspapers. Migrated in January 2004 from the Detroit, MI, suburbs to the Indianapolis, IN, area where he worked at a statewide legal newspaper for six years, just before finding the Diabetes Online Community and re-energizing his own local advocacy and personal diabetes writing style. Loves spending time with his wife Suzi and their black lab Riley, while also indulging his history buff tendencies and exploring family ancestry in his free time.
To learn more about non-medical switching and how it hurts people with diabetes, watch this video: