Fun with Formularies…. NOT!!

by | Apr 25, 2018 | Blog, Dealingwithyourdiabetes, Education | 0 comments

The Hell of Health Insurance

Anyone who has health insurance can agree that it is a complicated process. Proficiency in understanding deductibles and co-pays,  finding in-network providers, and balancing premiums with out of pocket costs should require a college degree. Yet most of us just muscle through it, trying our best to make decent choices, not spend more than we need to while taking care of our health needs. Being diabetic I am all-too-familiar with all the subtle rules, regulations, and fine print that must be addressed to play this insurance game well. Pre-approval – got it. Prior authorization – no problem. submitting an out of network claim – I’m your girl. Heck, I have a multi-tab spreadsheet with complex formulas to track my spending so I can forecast when I will meet my deductible (seriously, I do!). I would classify my skills in navigating the system as above par. Except for one part….

Formularies

I am reminded of this today as I prepare for a week of up-and-down blood sugars as a switch yet again to a different insulin. Humalog and NovoLog are the insulins that fill my pump and keep my fatal disease at bay. I have switched back and forth over the years, not based on which one is best for me, but on which one my insurance provider has negotiated the best rate with a Pharmacy Benefit Manager (PBM). The resultant list of approved drugs is deemed “preferred” and available at a lower cost.  This is the “Formulary”. In reality, both types of insulin are nearly the same cost, so it is purely a monetary incentive. Nothing to do with “health”. This article explains the game that is being played with my medication far better than I. Smart people at Harvard tells us how it all works (not to mention why it is so expensive!)

Not all insulins are created equal

Historically my endocrinologists have aligned themselves with the formularies – “Humalog and Novolog – they are the same” they say. But when I make a switch my glucose numbers tell a different story. I wish it was as easy as simply changing my basal rates x% for Novolog or y% for Humalog. But it doesn’t work that way. Each time I have to reinvent my insulin delivery. A week or so of extra checking, adjusting my basal rates, tweaking how much insulin for the grams of carbohydrate I eat until I get it figured out. Life or death? Not at all, but a totally unnecessary nuisance. Especially when good control is the Holy Grail we seek and is lauded by our providers.

I am happy to see some of the landscape of health insurance changing. More control and more choices in my hands and less one-size-fits-all policies are good for me (and you). My choice is to keep looking for a better way to beat the system – they are out there. Call me a rule-breaker, but this week I am like the GPS in my car “recalculating route”.

Be in Peace,

Patricia %

PS – Thanks KJ of Wilkerson Insurance for the shameless use of your tag line!

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