SOS!! Prescription Assistance Resources

Prescription medications. They play a huge role in the life of those with type 1. And they go beyond just medications - they include glucometers, test strips, lancets, pen caps, syringes, and so on. Many people with type 1 also live with autoimmune comorbidities, such as hyper/hypothyroidism or lupus, which means - you guessed it - more prescriptions. What many people don't realize is how costly these medically necessary medications and medical equipment can be, even after insurance coverage. For example, even with insurance coverage my co-payment for my insulin was roughly $230 for a 3-month supply. I am lucky. There are many people do not have insurance to soften the blow.

When you have type 1, getting your medical supplies can feel like a beast that you are expected to conquer all on your own, with no guidance. This may be why so many people fall between the cracks and struggle to care for their diabetes. Between living as a type 1 for almost 25 years and working in the field of medical social work, I have been privileged to glean handy information and resources that can help tackle this monster. Here is the quick and dirty handbook.

Terms to Know

Copayment. What you have to pay for your medication. 

Once your insurance pays their share (say, 80% of the cost of the medication), you are responsible for the balance (20%). Each insurance company is different in terms of how much they pay. Typically, insurance companies offer the most coverage for the cheapest medication, or the generic. As an example, your insurance may cover 80% of the cost of a generic (or formulary) medication, but 70% for a name brand (or non-formulary).

Formulary. The type of medication your insurance will provide the most coverage for. 

On the flip side, they will cover less (and you will pay more) for non-formulary or name brand. Then there are excluded medications/medical supplies - medications that your insurance company will not cover at all. However, if your medication is on the exclusion list, you may still be able to get coverage. 

Example: The insulin I use is on my insurance plan's exclusion list - meaning they do not cover it at all and I would be responsible to pay the entire price out of pocket. However, my insurance (and many others) allows my doctor to submit an appeal or letter of medical necessity for said medication. Once approved, the company agrees to cover the insulin as a non-formulary.
Get in touch with your insurance and ask what department can assist with this. It will likely be the prior authorization department.  If your doctor's letter/appeal is approved, your insurance may agree to cover this excluded medication to some extent- they won't cover as much as they would for a generic, but  they won't cover nothing.

Co-pay cards: Prescription assistance for commercial insurance - not for those who are on Medicare/Medicaid or uninsured. Co-pay cards can typically either be downloaded from the manufacturer website or given to you by your provider.
Prescription Assistance Programs: Programs that provide financial assistance/reimbursement for your out of pocket medication expenses. Typically those with Medicare or those who are uninsured are eligible. Applications can be made by mail or online, depending on the program.

Resources to Have

NeedyMeds. Probably my favorite resource when it comes to prescription assistance, NeedyMeds is a one-stop shop for assistance programs, downloadable coupons, and co-pay cards. Simply type in your prescription (you may need to know the generic name), and it will prompt you to choose co-pay card programs, assistance programs, or coupons, as they are available for that prescription. Link below:

http://www.needymeds.org/

Good RX. Another useful tool, Good RX provides a price comparison between your local pharmacies and downloadable coupons for your scripts. They have an app, or it can be used from your phone's browser or email. If you're old school, you can simply download the coupons and print them to take to the pharmacy. Link below:

https://www.goodrx.com/?kw=price&utm_source=bing&utm_medium=cpc&utm_term=goodrx|e&utm_campaign=Brand&utm_content=Ad-Group_GoodRx&msclkid=e01c282f134714ff51b9725fef046963

Whether you are uninsured, under-insured, or insured by a crappy plan, there are resources out there that can likely help. I encourage everyone to try out these resources. No one should have to pay exorbitant amounts of money to stay alive. Your doctor may be aware of other programs as well, so don't be afraid to ask them. You will likely need their help or their signature for some of the assistance applications. And this doesn't just go for type 1 - this goes for any and all prescriptions for any and all medical conditions.

Note: This post was written based on my experience, and is in no way an attempt at a thorough explanation of the ins and outs of insurance coverage. Each plan is different, and each person will have different experiences. Feel free to comment with different experiences or questions below.

It's Not You, It's My Insurance

Breaking up with your doctor

Is there anything more uncomfortable than a breakup? Especially one where there’s no bad blood (yet)? Perhaps not. Recently I had a change in insurance coverage. My new policy allows for lower copays and prescription discounts with a hospital group endocrinologist. Naturally, I jumped at this – I have only been seeing my adult endo for a couple of years, and while she is very kind and helpful, the pros outweighed the cons in regards to switching – especially cost wise.

As exciting as this switch is – as fellow T1Ds, you know how big a deal any decrease in out-of-pocket expense is – it has caused me a significant amount of worry. What an icky feeling, having to tell my doctor I am switching. I weighed the options on the drive to the office. What exactly would I say? Who would I tell first – the office staff, or the MD? Will they be offended? Will they fax my chart, or will I have to sign a whole heap of paperwork to release the records? As I sat with this discomfort, I felt an eerie sense of déjà vu. Thankfully, my APN and MD were incredibly gracious and understanding. I left the office with a bittersweet feeling. Reflecting on my visit, I felt familiarity wash over me – like I had just broken up with my endo.

So what to do if you’re in this jam?

Make your decision before you enter the office. Switching doctors is a big decision for someone with type 1. Typically the recommendation is to see your endocrinologist every 3 months. This is way more often than your annual PCP visit. If you’re super comfortable with your endo and are feeling secure financially, it may be worth the extra out of pocket to stay.

Stick to your decision. Once you make your decision, stick with it. Don’t waffle in the office. Professionally, the staff should understand that this is your decision even if they are sad to see you go. It’s okay to express these feelings on both ends, as long as no one gets carried away. Be kind, but firm. If you need a scapegoat, tell them you simply can’t afford to continue there. Blame your insurance. No one likes insurance anyway, doctors included.

Have your records faxed. Not all offices will do this, and some require a signed release of information. Be prepared to ask about it while you’re there, and have the fax number of your new doc handy. If they can’t fax it, they should be able to give you a hard copy to take with you to your new significant other.

Relationships – doctor relationships, romantic relationships, friendships – can be hard. Endings are usually inevitable. When it comes down to it, you gotta do you. As the wise men once sang, “every new beginning comes from some other beginning’s end.”