A Little Help From Our Friends Pays Off!

In 2007, I was diagnosed with Type II Diabetes.  My treatment started with diet and exercise, but quickly progressed to oral medication.  Not too long after that, I was testing at least six times a day with finger sticks, along with injecting long-term, quick acting, insulin in the morning, evening, and at mealtimes.

 I did my best to keep to a schedule but would frequently skip testing, or taking insulin, because my job responsibilities did not allow for a convenient place and/or time to do so.  I work on mission critical telecommunications and network equipment, which meant restoring services for clients took priority over breaks for meals and/or medicine.  As a result, my diabetes was uncontrolled, and my AIC were in the double digits.   Fortunately, my endocrinologist suggested I try the OMNIPOD system. This was a game changer for me as it replaced toting around insulin in a cooler bag.  With a continual feed insulin pump, and Freestyle sensors, this system replaced never-ending finger sticks to monitor my blood glucose levels with a simple scan of a sensor.  Now, I was able to do my job without interruption and my diabetes was finally under control.  My A1C now hovers around 6.9.

The company I work for provides my insurance coverage and as costs for coverage rise, they annually investigate ways to provide benefits to employees that are comparable year to year.  This past year they had to change our insurance provider to maintain similar coverage.  With previous changes, I have gone through the process to pre-certify the medications that have been prescribed and was successful in obtaining them to manage my Diabetes – with no increase in cost to me.  This year, however, the transfer to another major medical carrier, as of June 1st, created a nightmare. 

Several of the maintenance medications I take, as well as The Freestyle sensors, I knew would require precertification.  After going back and forth for weeks with the carrier, and the doctor’s office having to justify the medications, they were finally approved and covered under their pharmacy benefits – diabetic supplies to be exact – with no patient liability.   The Omnipod, however, was another story.  Through July and August, I spent hours on the phone with the carrier, DME supply companies, and my doctor’s office trying to get this very expensive item pre-certified and approved.  The information I was getting from the carriers’ customer service department regarding the insurance coverage for the OMNIPOD changed with every phone call.  First – it would not be covered at all.  Next – call the manufacturer and purchase it directly.  Lastly – it would be covered under Durable Medical Equipment (DME).

After many more weeks of back and forth, and more documentation than I care to remember, the carrier finally approved the Omnipod.  What came next, however, was the real shock involving the approval of this product.  The carrier advised I had to pay my full deductible before insurance would cover 70% of the monthly cost.  This translated to $1040 to pay the balance of my deductible to receive the first 3 months supply and then $312 going forward every 3 months.  And this deductible obligation recurs annually.  This was much more than I could afford!  The carrier understood my frustration and referred me to another DME vendor to compare cost, but they were even more expensive.  While I know many people pay a lot more for their medications and supplies, my dismay over this cost was predicated on the OMNIPOD being covered under pharmacy benefits by previous insurance providers with a very manageable $30 monthly cost! 

I was just about resigned to go back to finger sticks and insulin injections, but my office manager advised we reach out to our benefits broker and explain the dilemma.  Mike made my problem his own and contacted Empire.  He confirmed that the OMNIPOD is covered under DME but found out, by reading between the lines, that there is NO PATIENT LIABILITY for DME diabetic supplies under my insurance policy as long as the product is coded properly for Diabetic DME!   It seems every other representative I spoke with at the carrier, or DME vendors, were referencing general DME benefits.  

I am extremely happy to say that after 3 months of banter with the carrier, their pharmacy benefits department, their recommended DME companies, and the kindness of my doctor providing free samples to tide me over, I finally got notification that my diabetic supplies were being shipped.  The best part – needless to say – is that it was AT NO COST TO ME!  I am so relieved this is finally resolved.  I now go back to my responsibilities with my employer, knowing they, and their broker, have my back and provide me with benefits that can provide financial peace of mind for me and my family.