A diabetes diagnosis marks the beginning of a new health journey that involves some significant changes to your routine. Insulin and blood sugar tests become a part of your day-to-day life, not to mention all of the new insurance terminology related to diabetes medications. 

It’s okay, and very understandable, to feel overwhelmed after a diagnosis, or to wonder, what now? When dealing with any challenge, it’s important to take everything one step at a time. Diabetes is no different. The journey will likely feel much more manageable once you’re familiar with the key terms and have a good grasp of your diabetes pharmacy needs. The guide below offers a starting point as you build a strong foundation of information.

Diabetes Pharmacy 101: Key Insurance Terms

Diabetes treatment involves coordination with your doctor’s office, your insurance provider, and your pharmacy. You’ll probably start to hear the following terms as you work closely with each of them.

Copays, Co-pays

A flat amount set by your insurance plan that you are required to pay for healthcare services, procedures and treatments, including prescriptions. These amounts can vary based on the type of service and whether your doctor is considered in-network with your insurance plan. For example, you may have a copay of $30 for your doctor visit, $20 for one kind of prescription, and $50 for another type of prescription.

Coupons, Rebates, and Savings Cards

Many manufacturers of diabetes medications and supplies make their treatments more affordable through coupons, rebates, savings cards, trial offers, and free samples. Some of these savings options require you to register with the manufacturer (often on a website) or receive the coupons or samples directly from your doctor. You will generally need to do your own research to understand what savings options are available for the medications or supplies you’ve been prescribed. Alto automatically conducts thorough price investigations to identify potential savings.

Denials

Sometimes an insurance plan decides that they won’t cover the cost of a treatment, procedure, or medication. This is called a denial. These are some of the common reasons for it:

• Your insurance plan doesn’t believe the requested treatment is medically necessary

• The requested treatment is considered experimental

• There are typos or errors on the insurance claim

• The requesting doctor is out of network for your plan

• A referral or prior authorization is required

At Alto, we’ll look into the reasons for a denial and work with your doctor to either process an appeal or find covered alternatives.

Durable Medical Equipment

If you are prescribed an insulin pump or continuous glucose monitor (CGM), or need supplies like test strips, they will likely be covered under the Durable Medical equipment (DME) section of your policy. There may be restrictions on the brands or suppliers that are available.

Formulary, also called a Drug List or Formulary List

A list of prescription medications that your insurance plan will cover, including both brand name and generic options. They will be grouped by tier. Tier 1 usually includes generic medications and will have the lowest out-of-pocket costs. As you move up the formulary’s tiers, the costs will increase. If your prescription is not on the formulary at all, that means it is not covered by your insurance plan. 

Formularies can change as part of your annual insurance renewal. For example, your previous type of insulin may be in a different tier on the plan’s updated formulary, meaning you’ll pay more out-of-pocket to stay on that particular brand. Read our previous post on insurance changes to look out for when renewing your plan.

Medical Necessity

Insurance companies generally consider a treatment plan to be medically necessary when it follows accepted clinical guidelines and practice. To determine this, your insurer is likely considering whether the proposed treatment is:

• Clinically appropriate in terms of type and frequency

• Generally considered effective given the diagnosis

• Not more costly than other options that are likely to produce the same result

• Not selected just for convenience to you or your doctor

Patient Assistance Programs 

Patient Assistance Programs, also called PAPs or Diabetes Care Programs, are financial assistance programs created and managed by the manufacturers of diabetes medications and supplies. These programs are intended for people without insurance or when copays are prohibitively expensive. Keep in mind that these types of discount programs may result in your medication costs not counting toward your insurance plan’s deductible. Alto will search for these potential sources of financial assistance as part of our price investigation and ensure you’re getting the lowest possible price.

Pharmacy Benefits vs. Medical Benefits

Not all diabetes medications and procedures will be covered by the same sections of your insurance plan — most plans have separate medical and pharmacy benefits. Medical benefits are usually used to pay for the professional services your doctor’s office provides, a hospital stay, or medically-necessary labs and tests. Pharmacy benefits are used to pay for most prescription diabetes medications, including self-administered oral and injectable medications. 

Many commonly prescribed devices, like Continuous Glucose Monitors (CGMs), will fall under different categories. For example, FreeStyle Libre® and Dexcom® may be billed as either pharmacy or medical benefits; and Medtronic Guardian™ is only billed as DME.

Prior Authorizations, also called a Pre-Authorization

Not all healthcare services and prescriptions are considered equal by your insurance plan. If the requested devices or procedures are more expensive, experimental, or new to market, your insurance plan may require you to complete a prior authorization before they will agree to cover the treatment. These forms provide the insurance plan with information from your doctor about why the proposed treatment option or medication is appropriate or necessary. For example, you and your doctor may need to complete a prior authorization to explain why your insulin pump or CGM is medically necessary and provide supporting documentation from your medical records.

After reviewing the documentation, your insurance company will approve or deny the request.  If approved, you will be able to receive the requested treatment (although there may be specific instructions in the approval about how you obtain the care, e.g. by using a specific physician, pharmacy or other supplier). If your prior authorization is denied, you will work with your doctor to determine if you should appeal the decision or pursue a different course of treatment.

Alto’s dedicated support team will coordinate closely with your doctor’s office on filing prior authorizations to help you get the diabetes medications and supplies you need.

Common Issues With Insurance Coverage of Diabetes Medications

• Your insurance plan may limit the number of test strips you can purchase in a specific time period, though it may be possible for you to apply for an exception.

• If you haven’t previously used an insulin pump or CGM, your plan will likely require a prior authorization. They may also require you to start on an older version of the device with fewer features.

• Patch pumps may be covered under pharmacy benefits or DME benefits.

• Your plan may designate where you can purchase pump or CGM supplies; some will allow you to purchase directly from the manufacturer. 

Check your plan’s DME policy for more details.

What to Look For in a Diabetes Pharmacy Partner

Having a reliable pharmacy partner is especially important with a condition like diabetes, which involves a learning curve with medications and supplies and frequent communication with insurance. We recommend looking for a pharmacy that has significant expertise in diabetes care. Here are some questions to ask yourself as you explore your diabetes pharmacy options.

• Does the pharmacy offer free delivery of your medications and on-demand pharmacist guidance for injections?

• Does it understand the temperature-controlled needs of insulin? Does it store and package the medications correctly?

• Can it help you navigate your insurance benefits, assist with prior authorizations when needed, and connect you with DME suppliers if appropriate?

As you navigate life with diabetes, it’s important to feel surrounded by support. If a pharmacy meets the criteria above, you’re more likely to feel like there’s always someone in your corner.

We’re here to provide exceptional diabetes care

At Alto, we understand how stressful it can be to get started with diabetes medications and coordinate with insurance. That’s why we have a dedicated team for support with diabetes. We offer free same-day delivery of medications and supplies right to your doorstep, and we handle everything behind the scenes, too, from investigating cost-saving opportunities to submitting prior authorizations and more.

Get started or learn more about Alto by reaching out at any time via phone at 1-800-874-5881 or in-app messaging.

This content is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or another qualified health provider with any questions you may have regarding a medical condition.