Prior Authorization and Diabetes

No diabetic wants to hear their pharmacist say they need a prior authorization. But most people with diabetes will require a yearly prior authorization on their insulin, test strips, and pump supplies.

The insurance company issues a prior authorization on expensive medications and supplies that they don’t want to cover. Often insurance companies change the insulin given or the type/number of test strips dispensed. It’s not uncommon for insurance companies to limit diabetics to testing three times a day. Even if the doctor wrote a prescription for 10 test strips a day the insurance company can deny that amount. Insurance companies can also change the type of insulin dispensed. They do this based on deals they make with insulin manufacturers. This year Blue Cross and Blue Shield has partnered with Novo Nordisk and is issuing prior authorizations on all insulin that is not NovoLog. This means people who use Humalog or Apidra have to be switched to NovoLog to continue to be covered. If they refuse to switch insulin they will be responsible for the full cost. Switching insulin is a big deal for diabetics since not all insulin is identical. This is especially true for people switching to and from Apidra. Apidra is a slightly faster acting insulin compared to NovoLog and Humalog. This switch can affect blood sugar control.

A prior authorization can also easily delay a prescription from being filled by several weeks. When it comes to life-saving medications and supplies many diabetics cannot wait weeks for their medication to be filled.

To address a prior authorization the pharmacy must contact the prescribing physician. The prescribing physician must then contact the insurance company. Physicians will often comply with the insurance company’s request because it is easier and more cost-effective for their practice.

A prior authorization can be delayed if the pharmacy does not immediately contact the doctor. It can also be delayed if the doctor if the doctor does not contact the insurance company. Even after the doctor contacts the insurance company there is still a 2-3 processing period. Sometimes doctors fight the prior authorization and try to get the diabetic what they need. This can delay the process of getting the prescription filled even longer. Many Type 1 diabetics have reported waiting over a month for their test strips to be filled. This is exactly what the insurance company wants–one less month of paying for test strips. In the end, the diabetic suffers and the insurance company profits. The system is unfair and ultimately the patient suffers or takes on the financial burden of paying for what the insurance company denies.

Prior Authorization

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