What do you do, go to your local pharmacy to meet your monthly insulin or other diabetes prescriptions, and find out that your health insurance company has switched your medication without knowing your doctor (or you!)?
This practice is called “non-health switching,” and occurs when health insurance companies remove eligible prescriptions from their health plans or move them to a higher class in their plans, making your co-payments prohibitively expensive. Plans usually do this to save money.
The effects of non-medical switching can range from slight nuisance to very negative medical results.
In this post, we explain why insurance companies sometimes switch between diabetic medication and options to sue decisions.
How does a health insurance company decide which medications to cover?
According to Express Scripts, health insurance companies will first consider the effectiveness of drugs, not necessarily the cost of the drug, when deciding what to cover.
Health plans usually have a committee of doctors and pharmacists who review the information used by federal regulators to approve the drug, in addition to other similar drugs on the market before making a final decision.
All health plans in the US cover insulin, which depends on what kinds they are trying to cover.
What is a non-medical switch?
Non-medical switching is a common cost-saving tactic used in many health insurance plans in the United States.
It happens when an insurance company changes the terms of the contract or the cost of a stable patient’s medication. The “switch” is not for medical reasons, but it is often a cheaper version in which health insurance companies are considered to be exchangeable for older medications that patients have been prescribed.
This exercise is different from “step therapy,” in which a patient must first “fail” with a drug before the health plan covers more expensive ones.
Think about it: force diabetics to use older human insulin (such as R or NPH) and ultimately use high A1C.
According to the US Pain Foundation, the non-medical switch costs more than $100 billion a year to the US and directly injure patients who are otherwise stable with prescription drugs.
Is switching outside of medical care always an issue?
It is important to note that switching outside of medical care is not necessarily a bad thing.
First of all, practices are less common, so if you have a newly diagnosed, don’t worry until it actually becomes a problem.
Secondly, if you are taking medications but switch from your health plan to a newer version of the same medication that works even better, or a medication that works perfectly interchangeably with the old medication and realize there is no difference, there is no problem and there is no reason to worry.
If your medical plan changes your medication to another medication, switching medical care is a problem.
How to undo non-medical switching
Having your medication changed last minute can be very frustrating, especially if you’re doing well with it. The good news is that you don’t have to fully embrace these changes.
There are a few things you can do to appeal your decision to switch diabetic medication. Here’s a step-by-step guide:
Call your doctor
The appeal process can take time, so it is important to immediately notify the diabetes team of any changes you have experienced at the pharmacy counter. Your doctor can provide advice on how to change the dosage, if applicable.
If you don’t want to use or use new prescribed medications, but older medications are very expensive, then over the American Diabetes Association and Type 1, they gather a wealth of resources for patients who need to help get their medication.
Request an old medicine
If you’ve been using a certain type of insulin or medication for several years or more (with the same health insurance plan), your insurance company will not usually change your coverage, but that happens.
If you don’t want to try new medications, you should call your health insurance plan immediately and request an old medication.
In your health plan, you may say that the particular prescription drug they are requesting is a medical need for you and that you cannot use it interchangeably with another inexpensive drug and that you will need prior approval (PAR) from your doctor.
Previous approval requests must be submitted through a medical professional. You cannot submit it on your behalf.
Because the PAR process is a way for insurers to reduce costs (and avoid covering more expensive drugs for their clients), some people run into these issues many times a year.
Have your doctor request “99 months” for your previous approval. This will not make this headache an annual event.
In a 2018 study in the Journal of Current Medical Research and Opinion, the researchers looked at 451 people with type 2 diabetes for their experiences with non-medical switching.
After switching medications, one in five people were told by their doctor that their blood sugar levels were slightly or far worse than they had been taking previous medications.
Also, about 20% had to check their blood sugar levels more frequently than before switching. This can be a physical, emotional and financial burden.
Additionally, one in four people said that non-medical switches had negative effects on their mental health.
Request a peer-to-peer review
If your health plan rejects a request for backing your old medicine, you can request a peer-to-peer rating. A doctor can award the doctor and the health plan physician to discuss why a particular medication is medically necessary.
This can solve the problem without going through a long appeal process.
Submit an appeal (internal review)
If you are struggling with a new drug and cannot afford the old one (by paying a higher co-payment or paying from your pocket), your doctor can appeal the insurance company’s decision by requesting an internal review.
Please note that this is a long process and there is no guarantee of success. To file an insurance appeal:
- Collect letters of rejection from previous attempts to retrieve the old medicine. This is sometimes called a decision.
- Please check the description in the bonus document to ensure that the denial was not incorrectly made. You can call your insurance company’s customer service line to get more information about your original denial.
- Call your clinic and let them know that you are requesting an appeal. They can help you write an appeal letter on your behalf, and even help you fill out the correct form.
- Blood glucose data will be tracked for several weeks. Yes, we are publishing old school logbooks (or diabetes apps). This can be used as evidence of complaints that new drugs have negative consequences for diabetes control.
“It’s important that the documents to demonstrate your claim that the new drug is not appropriate. If you can provide a document that says the original drug worked, then the insurance company is usually fine,” she says.
“But you need a lot of documentation to prove that it is necessary. If you’re switched, write down your blood sugar readings, write down how your new medication makes you feel, and write down all the changes you notice.”
Submit an external review
Internal reviews may not work for patients, and insurance companies are stuck with their original decisions. Don’t worry; you can also request additional internal reviews or external reviews.
Performing an external review means bringing in a fair third party to determine the issue. The final rejection letter for your health plan includes information on how to apply for an external review and how to use it to be required time frame (usually 60 days after the final rejection).
After a third party makes a decision in an external review, the health insurance plan must legally accept it.
What are people doing about this?
Thankfully, many patient advocacy groups are trying to make sure it doesn’t happen to more people in order to solve this problem.
Additionally, many states are beginning to ban non-health switching or limit practices.
For the past few years, California and Nevada have adopted such laws. States like Florida and Tennessee have also considered similar laws, and Massachusetts has formed a committee to investigate the idea. Colorado has banned certain drug practices.
However, even if you choose to be involved, health and diabetes management should not be compromised for the bottom of your health plan.
