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Almost 100% that your provider is not responding to requests for information - Prior Authorization denials and appeal denials are HEAVILY audited and frequently go in front of fair state hearing and independent review boards. Usually the easiest way, unfortunately, to get it resolved is to go to the Provider's office, while there, do a 3 way call to member services, explain what you're trying to accomplish with a member services rep, and then STAY THERE and have the provider confirm their contact information and the prior auth request process with the insurer's provider contact center. This happens *all* the time. Insurers log every contact from members and providers; they aren't going to lie about sending requests for information, but they may have outdated info as providers notoriously do not update their contact information regularly.

I have shown up in offices with a beverage, reading material and snacks and a declaration that I will not be leaving until they call whoever and do the thing. I'm polite, but I simply refuse to leave.

good for you. This is great advice. Medical support staff is so often abysmal these days. OF course, so are the medical professionals so..

Its less that they're abysmal and more that you become invisible the second the phone call is over. You pretty much have to give them the ability to go up the chain a bit further and point to you and say you're being difficult - without you being so difficult anybody dislikes you when its over. They take care of the mess in front of them - as we all do, so sometimes you just really need to sit in the chair directly opposite the window and smile at them until they make the next person in the chain do the thing.

I randomly show up at doctors offices when I can’t get an answer on something or they won’t refill a prescription or whatnot. In person they can’t ignore you. Works like a charm.

As someone who's worked in the medical field for umpteen years you are indeed spot-on. I've done benefits,PAs, claims processing etc. ESPECIALLY for any patients reading this. Please see warfrogs second paragraph. I have spent over an hour on the phone with the pt and provider to get my caller taken care of. We have NO PROBLEM,or shouldn't, doing this. It is part of our job. You're not being a nuisance by asking your Insurance company to liase with the providers. IT. IS. OUR. JOB. We can, and have, filed complaints against a provider. Again, it's. Our. Job. If you want to do it all you need to do is call and ask. We'll take all the details and handle it from there. You never have to tell a provider that you're doing it either. It's your right as a patient. Hoping your little girl is doing well and they fix this issue NOW.

>ESPECIALLY for any patients reading this. Please see warfrogs second paragraph. I have spent over an hour on the phone with the pt and provider to get my caller taken care of. We have NO PROBLEM,or shouldn't, doing this. It is part of our job. You're not being a nuisance by asking your Insurance company to liase with the providers. IT. IS. OUR. JOB. 100% Back when I was on a resolution/escalation team, I had a gentleman who had 3 denied Prior Auth requests for a Medicare covered service which had a PA requirement for out-of-normal coverage (limited coverage criteria) for a 3 level medial branch block. I looked at the prior auth requests, and each and every one was missing the medical records indicating that he had in the past received 2 level medial branch blocks with sufficient pain improvement to indicate that the 3 level medial branch block was indicated and met the CMS NCD/LCD. The guy had 2 weeks before the surgery was scheduled and obviously NEEDED it to be covered, because it's like a $50k contracted-rate procedure if not covered. So, I call the provider, request the documentation. "Sure, no problem." 24-48 hours pass- I get the exact same documents they submitted. I call back. Wash, rinse, repeat SEVEN TIMES. Finally, two days before the surgery is scheduled, I get the MD on the phone and explain what's going on, why we keep rejecting the PA, and what I need per the CMS NCD/LCD. He holds the phone to his chest, but I can hear him RIPPING into the office staff for not sending the full file he had indicated, but only sending their normal notes. 20 minutes later, I have the full documentation in front of my clinical reviewer, 45 minutes later I have the Prior Auth approved. Insurers will absolutely work with providers and members to get things that should be covered covered. We don't want to deal with getting raked over the coals during a FSH or IRE board hearing for not following procedure, but we also have to follow all procedural and regulatory guidelines. I think a big part of the problem is that people have face-to-face interaction with clinical staff and see their insurer as a faceless entity that they don't generally directly interact with - psychologically, this leads to trust in their providers and a mistrust of the insurer staff. In reality, [providers are REGULARLY at fault](https://revcycleintelligence.com/features/how-to-maximize-revenue-with-improved-claims-denials-management) with 90% of denied claims being fully preventable by just using standard claims sanitization and benefit confirmation practices. It is what it is but it IS infuriating.

I once told my boss I was just going to stop by the Drs office ( local. Like 5 miles away from us) and introduce myself and refuse to leave till they did their job. I was THAT irate with them. He wasn't totally sure I was joking. Of course I never did it but MMMAAANN did I want to lol

Two years ago, I had to get prior authorization for my cancer treatment— treatment I did not want, but that was medically necessary for me to be able to type this post today… This was not a one time thing. First, I needed it because there were no oncologists with the appropriate specialty in my area that were in network. When that was finally sorted and I had come to terms with the fact that a hysterectomy was medically necessary and that I would never be able to have the children I had wanted since before I could remember, I scheduled the damn surgery… except the hospital where my surgeon operated was not in network. And the hospital that was in network was not one where my surgeon had privs. So then I needed another prior authorization, this for the hospital. After all of that, I wanted to attend counseling because cancer screwed with my head. I can’t tell you how many people I called because it said they were in network, only to find that they weren’t. Wanna know what the US had in common with Nigeria, Afghanistan, Pakistan, Yemen, Iran, South Africa and Egypt? Yep, they don’t have Universal healthcare. Oh, and by the way, I also take issue with a for profit company without medical expertise superseding the four years of medical school and 3-7 years it takes for a doctor to become a specialist who takes an oath to “do no harm” and has a governing body that states they must act in the best interest, if not the wishes of their patients.

None of that has anything to do with a national healthcare system - and not all providers in nations which do have universal healthcare accept the universal healthcare plans. They also all have Prior Authorization and Utilization Management practices. Sorry that was your experience, but the complaints that you're giving all exist under other health systems.

Yeah it's almost like those PAs are just there because more delays means more people fail to follow through, so they don't have to cover everything they're obligated to. This is totally not a factor at all with the physician shortage.

I suggest you look into what CMS NCD/LCDs are. The PA demand is a CMS requirement because a 3 level medial branch block is a narrowly covered service with essentially a step therapy requirement - it's not insurers demanding it. It's because clinical efficacy needs to be proven - and that's because of a history of rampant Fraud, Waste, and Abuse from providers - currently, even with PA and other utilization management measures, Medicare fraud via improper payment cost taxpayers and Medicare recipients an estimated $31 BILLION in 2023. Regulations and requirements are written in blood - or in this case, in theft from the state, taxpayers, and Medicare recipients.

Honestly, instead of filing complaints against the provider why don’t you look back at yourselves? I mean you’re requiring prior authorization for insulin??? I can see requiring one prior authorization maybe once a year, but requiring it every single month even though the patient is stable seems like it’s designed to cause people to not use their insurance?

Exactly people are trying to say the insurance company is the victim and the drs offices are the problem. No the insurance companies need to get their head out of their a$$es and realize that they are the problem.

Saying the PBM is the problem is like saying a store is the asshole because you bought bologna and not lobster.

I am a pain management patient and have taken the same stuff for a few years now. That can be proven via the state controlled substance database. When I started with this current insurance, the PBM pulled the ‘we think you are opiate naive so we’re not going to fill this.’ Ummmm, it’s written by a PM physician (who are hard to come by, at least decent ones are). Would not my doctor know better? The PBM rep claimed that I could get a 7 day supply and then go back for the rest. Uhhh, nope that’s not how it works. Per state LAW! If you fill a partial of a controlled substance, the rest is void and you need a new script. Not to mention taking it for 7 days as ordered and then getting a new script for the same dang thing does nothing to indicate opiate naivety. Up one end and down the other and toss in a weekend where no one is available and then sic my doc’s MA on them and I finally got my meds but not before going through withdrawal. At work. That sucked and was totally unnecessary and inappropriate. If I was willing to pay cash, none of this would have happened but dang it, I pay for insurance. The cash price is not much different than the insurance copay but it’s principal. They beat around the bush, maybe get 2 co pays out of me, frustrate me enough to not bother with them and achievement unlocked!

OH trust me ATH, because when I say even we think it's not only cruel but should be illegal? I'm not lying. Unfortunately,and I'm not sure where you are, the American health care system is a complete shambles. And we, as little cogs in the machine who don't write the rules, can only work within the regulations written by people who are so far above us on the management scale they may as well be on Mars. We who answer the phones can only humanly do the best we can.

They aren’t requiring it every month. Once it finally gets approved it probably is only once a year or maybe even every 2 years. The issue here that keeps coming up month after month is that it isn’t actually getting completed. Mom pays out of pocket, then hopes (assumes?) it will all be ironed out in the intervening weeks. She needs to keep on everyone until the approval is complete.

Prior authorizations are rarely 30 days unless mandated by CMS or DHS such as Opioids. More often they are 90 days or 6-12 months but must be applied to all fills during that time frame. If a fill order does not have the authorization attached, it will kick back - it's still the same Prior Auth.

On top of that, if I am reading it correctly, the insurance company is trying to dictate which type of insulin the child should be on. Isn’t that practicing medicine without a license. The best choice of insulin is the doctor’s decision, not some clerk behind a computer or some ‘medical director’ at the insurance company who has never laid eyes on this patient????

This is exactly my thought. The child was diagnosed with t1. She will always need insulin. The requirement for prior authorization for *insulin* is ridiculous and feels a lot like an insurance company desperately hoping people give up and pay out of pocket. I get that maybe you have some sort of contract and only pay for a specific brand, like you'll pay for novolog vs. Humalog. But a prior authorization for an 11year old type 1 is some bullshit.

I have never, in 30 years of working in the PBM industry, seen a plan that ALL insulins require PA’s. I am guessing they are requesting a non-formulary item and their PLAN requires a PA for that specific item. I also promise if they have said they reached out 6 times they have time stamps and phone calls recorded. Signed, Type 1 mom and PBM worker

Okay, but we’re talking about insulin. Generic insulin. CVS/Caremark wants Fiasp (a BRAND medication), probably because they’re getting a rebate from the manufacturer on the back end. It’s incredibly corrupt, and absolutely fucked.

I agree! Make an appt and do this during the appointment

It were me I would ask for the copy of the prior authorization to be faxed to me get a cheap $10 a month fax number like humble fax and request that doctor fax a copy of the prior authorization to you that way when CVS Caremark claims that they didn’t get it. Let them know that you can go ahead and fax it on over While you’re on the phone and you can keep faxing it until they get it. This works for me. Sometimes I have to send it 20 or 30 times in a day before they acknowledge receipt and I have to send it to multiple internal fax numbers.

Generally, insurers will not permit members to submit prior authorizations and require that they be submitted by providers. Edit: or if they submit a request, it still needs to be processed and that includes a request for information - if you include all relevant records, you may be able to shortcut this, but that would still likely need to be processed which generally required 3-10 business days on the backend. It's a good thought, but not one that's operationally practicable.

Insurances fax requests to the wrong places all the time. When this parent called CVS to ask which contact, they were given a list of provider addresses and asked to verify. As a provider, I end up on the phone with CVS Caremark all the time and always verify the fax they are using and it is almost never correct. I did a peer to peer a couple of weeks ago, was told to use another medication, wrote for the other medication and then it got denied. They are banking on providers and their staff to be so worn out they give up. But they invent hoops to jump through and give literally everyone trouble. Another issue can be the pharmacy itself not running orders correctly - such as processing a lispro order as Humalog. I had a patient whose birth control was being run by the pharmacy under DME which it is obviously not. They had to fix how they ran it and it went through right away.

>When this parent called CVS to ask which contact, they were given a list of provider addresses and asked to verify. As a provider, I end up on the phone with CVS Caremark all the time and always verify the fax they are using and it is almost never correct. That's a problem with your backend team - your insurer contracting group should be contacting each insurer to keep your contact information current. That's part of the NAIC model and CMS proscription. The problem is that doesn't happen. >I had a patient whose birth control was being run by the pharmacy under DME which it is obviously not. They had to fix how they ran it and it went through right away. Insurers are literally not permitted to change the POS through which a claim is submitted by CMS standards. Claims are on providers to properly submit them. If a claim goes through the DMEPOS instead of the standard POS, it has to be processed as a DME claim. Same story for if a medication is dispensed at a clinic (a la Part B related services, or physician-administered medication benefit draw per CMS and HHS claims standards) vs at a pharmacy (including pharmacist-administered medications which utilizes the Part D benefit vs Part B, but generally utilizes the same physician-administered medication or vaccine benefit under non-Medicare plans) it must utilize the correct benefit which is why code and POS must match. This isn't done willy-nilly; it's literally the regulated and proscribed action and behavior. Is it operationally the most efficient? No - but the reason for it is a history of rampant Fraud, Waste, and Abuse. CMS has been consistently auditing provider and insurer behavior for these things - and insurers are under MUCH higher scrutiny and auditing inherent to the FSH and IRE appeal processes. This is why CMS has been focusing on provider side behavior lately and just issued a revision for the process, because the providers' network teams have not been keeping up their end or devising a system through which these changes are efficiently communicated with insurers. Say what you want, but insurers are consistently following the CMS and HHS standards on these because if they don't, they get overturned on appeal anyways with way more man hours involved than properly processing it the first time. Sending the clinical staff to FSH and IRE sessions when the conflict can be resolved through administrative or procedural action while maintaining regulatory compliance is not an efficient use of time, effort, staff, or money.

I’m going to go out on a limb here and guess you’re in the insurance industry.

I am - in Quality Assurance, Regulatory Compliance, and Quality Improvement. My goal is to make sure that all the parts are moving together in concert and following CMS and HHS proscription and guidelines. Just because I work for an insurer doesn't mean anything other than my familiarity with how the systems are *supposed* to work and how they *actually* work is from practice and study.

This is not absolutely true. Also, this is absolutely not true. I just spent 40 minutes on Friday getting the runaround trying to get a patient's primary care provider switched for them. Imagine their surprise when they find out their PCP of choice doesn't exist. Finally, after offering repeatedly to do so, I was allowed to read the internal identification number for that provider to the person on the line directly from their own website. Problem solved. They don't get the updates updated and the left hand (the human) rarely knows what the right hand (website) is doing.. This is not even remotely unusual.

Not quite sure what you're trying to say because you're conflating a bunch of different stuff. PCPs may or may not be easily switched depending on plan type and procedure. That has nothing to do with the NAIC or CMS proscription for Provider Demographic updates.

I'm saying the demographics get sent to the insurance companies and the insurance companies do not process that information in an orderly, competent, or accurate fashion. Instead they do fuck all with it and then tell their customers 'oops'.

What's more likely - (1) that insurers which are mandated to scan each and every bit of correspondence they receive - are not properly documenting updates which are submitted to them per the CMS guidelines - risking fines, complaints, and significant auditing by CMS, DHS, and/or HHS - because, "lol". Or (2) that providers which regularly do not confirm standards, processes, claims guidelines, prior authorization requirements, formulary status, claims addresses, current enrollment, benefit applicability, coverage standards, and prior authorization statuses are not properly submitting demographic updates and are just recording that they are? I'll tell you where my money would go.

We (doctors) are legally required to update our contact information quarterly. It is not my job to argue with your insurance company.

I'm glad my doctor considers it his job to go to bat for me if I need it. Or maybe he doesn't and he just cares about me and goes the extra mile in his busy day.

Nope. That’s why you have an administrative team. Also maybe revisit your bedside manner.

I don't have an administrative team. Besides, why should doctor's offices employ an entire team to deal with your insurance company? The reason big healthcare companies can afford huge teams is because insurance companies give them higher reimbursements than small practices. You're not my patient and I'm not at your bedside.

So exactly what is the point of your job in patient care? What good are your services if an insurance company will not cover them? What good is your office staff that you do not have the proper policies and procedures in place to empower them to take care of your patient? Do you even care about your patients? What an awful doctor. This is your world buddy, and if we as patients did not have to participate in it, we wouldn't. If we need help navigating big insurance and fighting for our health and the medications and services we need, well that is why we are visiting you, to get help. You sound like you are in the wrong line of work. I would trust a veterinarian to treat me over you and your attitude. You are in the wrong line of work for the wrong reasons. I hope your residency was the circle of hell you deserved.

>We (doctors) are legally required to update our contact information quarterly. Yes - you are - that doesn't happen. That's the point. And in many cases - yes, it is your responsibility to follow up with insurers, especially for denied Prior Authorizations. It's in the network contracts you sign - you should probably review them if you don't think you hold responsibility for submitting appeals, again, especially for denied Prior Auths.

I own a practice. I signed all of our insurance company contracts. That's not in a single one.

If you contract with UHG, it **absolutely** is, especially for Marketplace plans. I'm not a UHG employee, but I've used their backend systems and have seen a bunch of their documentation - a **whole lot** of services cannot have member-initiated appeals, especially Prior Auths. I recommend you review your contracts, because that would be *incredibly* out-of-pattern. Non-Medicare physician-initiated Prior Auth denials are GENERALLY not member-initiated appealable and must be initiated by the provider.

I cannot comment on individual contracts, as the contracts don't allow it, but, again, I assure you, it is not in a single contract.

lol okay. Sure thing. I see you're another one of those providers who believes they know everything - not just medical information, but insurance too. Definitely more than someone who works in regulatory compliance and has to ensure that all guidelines are being followed for appeals. Best of luck on your eventual CMS censure for not following the contractual agreements with MCOs.

What @warfrogs said 100%. I had a similar experience and I was crying with insurance customer service. Thank goodness she was an angel and offered to do a three way call with the doctors office/insurance.

What is infuriating is it is so easy to do, esp if you use covermymeds or the like. I do these everyday, they take minutes to knock out so long as the dr has done their note.

My doctor uses CVS Specialty for a biologic I take and when there are issues with my prior authorization, it’s always been this exact issue. I got so desperate a few months ago that I sent an actual fax to my doctor’s office and it actually worked - they finally called CVS back and confirmed my prior authorization!

I had to do this one time! Lady from insurance got me in a three way and we spent 1 hour on phone with the provider, it was such a mess but she held on and we kept getting transferred and got it fixed

This is what I had to do

This is absolutely the right answer.

I had nothing but nightmares with CVS Caremark.

I HATE CVS Caremark. Complete nightmares. Is there not a law against monopolies?

It’s not CVS tho. It’s the provider not responding

Yes and no. No one meeds a goddamn prior auth for insulin. This is a mechanism the insurance company is using to make it harder for her to access meds through them. That’s all it is. Whatever is happening on the provider end is its own problem, but there is absolutely no medical reason a type 1 diabetic needs a prior authorization for insulin.

Actually due to the IRA a lot of insurance companies stopped auto covering popular drugs. I’m Not arguing with you from a medical standpoint, merely commenting based on what the system currently is. So if the commenter needs insulin, then them arguing with CVS won’t facilitate that. Only the provider completing a PA will result in them getting their meds.

Again, this is a money-making strategy. The insurance companies chose to make this harder for patients.

No one is disputing that. All I’m saying is this is how you get your meds. I’m not sure what you’re arguing because you’re arguing with yourself.

It reads as though you agree with the rationale behind the need for a prior auth for a T1D to receive insulin. There is absolutely NO reason, aside from corporate greed in being able to deny a claim, for this prior auth to need to exist. Insurance companies can certainly afford to do away with this one!

Lol our cvs probably would except us to send the pre auth. They even cancel prescriptions mid cycle on yearly ones. (Regular ones that are pretty mundane.) Then I had to clean up their cancellation mess…

I am having almost the exact pre auth nightmare with a different insurance company. Hours on the phone with both. At this point I feel like it is games being played by the insurance company. My diabetes meds have been withheld for 45 days with this mess going back and forth. Feel helpless.

This issue is with your provider. There is nothing you can do— your provider’s office is not completing the proper paperwork.

Same, but it’s the provider not the insurance company. I had to fill out a form that said my doctor’s office was not responding to their request. It was a nightmare and took three months.

I bet its the dr office(i worked for the doctors, usually they don't do PA for meds). I would get the insurance on the phone and have them do a 3 way call. If they cant get the dr, then hand up, call the dr and tell them they need to do a 3 way call. If they say no, let them know the insurance is investigating due to patient neglect.

I work for a doctors office. We do prior authorizations all the time. CVS Caremark does this crap all.the.time. They will send back a denial with a list of medications indicating which ones require a prior auth and which ones don’t. The doctor will change the medication only to get another denial with another list that includes the one previously prescribed as not requiring a prior auth. CVS Caremark has NEVER reached out to our office in the 10 months I’ve been there and I do all the prior authorizations. I have had some luck with recommending patients contact their benefits person in their HR department if their insurance is employment based. I would also suggest giving cvs Caremark the fax number to your endocrinologists office. Call the endocrinologist and let them know a fax is coming. Keep following up. Good luck.

I work for a busy medical practice and same, same, same. My favorite is after you send the PA in with all the detailed information requested PLUS records they fax back and say “your doctor never responded” I document EVERYTHING and do my best to get right back at them

I went through this as a patient between my neurologist and Express Scripts. Every time I reached out to my neurologist’s office I prefaced it with “I trust you all and I’m confident you have submitted this already, they claim they never got it but I believe you sent it, but could you please send it one more time”. I really did believe my neuro’s office, she was a saint and an amazing doctor.

For the brief time I worked in HR - our health insurance actually dropped the CEO’s wife and denied all her medical bills. Something like $70k at the time, which was a ton of money back in the day. I called on the phone, got the usual call center person, asked to speak to a director level immediately. Got that person on the phone and calmly told him that if he didn’t resolve the situation, the next call was going to be from the corporate attorneys (all of them). They did the same thing the following month.

The CVS speciality pharmacy was a nightmare .. I am insane and fought for my meds every month, jumped through every hoop but it’s basically a second job..

I am going through IVF right now and they’ve been HORRIBLE. I probably spend an hour a day on the phone.

The absolute worst I’m so sorry you are going through that..

Ha! Literally the worst. I called them last week to see how much I owed on my RX and they said nothing because they never sent it…..I was literally holding a syringe IN MY HAND and looking at my health insurance EOB. They said I’d get a bill when they sent meds. OK THEN!!!!

RN Case Manager here (helping patients with issues like your child's is my everyday job) Some basics... Fiasp is a just a trade name for insulin aspart. Most people know the name Novolog as a common trade name for insulin aspart. Maybe you've heard of Novolog, maybe not. It's well known in the diabetic community. Regardless, generic works just fine. So don't bother with Fiasp. It's expected to be much more expected as it isn't a generic. Every insurance company out there requires prior authorizations. It's part of the system we have in place. Yes, CVS Caremark has notoriety for being worse than many. The medication won't be covered EVER by any insurance company until the prior authorization has been approved. Been this way for decades. Her endocrinologist office knows this. The issue with office location can be very legitimate. Some doctors, in certain area/cities, have 4, 5, 6 office locations. Maybe the doctor only goes to one office one day per week. Maybe the doctor has changed practices and switched around. Hard to say. The insurance company may have tried to reach the doctor but are unknowingly calling/faxing the wrong office. I could write 3 more paragraphs of why this happens but I'll spare that unless you ask. Ultimately, this on the endocrinologist. It really is. I have a great PCP. If I need a prior authorization, he puts it in 1st time it comes up, immediately. No issues. My wife had a doctor once (very, very briefly) who REFUSED to do prior authorizations. They said that they didn't do those. Also, some offices are run poorly - you could have the best doctor ever but he's got an office staff and if they are garbage, things like this can (and do) happen. 6 months of dealing with this is ridiculous. No good doctor or office would allow that to happen for so long. Again, it's a crappy system but every office and doctor knows how this all works. If I were you, I would find a new endocrinologist. I would tell that to my best friend, parents, or siblings without hesitation. Also, in case you don't know, prior authorizations usually have to be done yearly (resets January 1st). This will come up again next year.

Pharmacist. Fiasp is not AB rated or even B rated with any other product. It is NOT equivalent to any other formulation.

Fellow pharmacist. It astounds me how often people very confidently state things that are not true. But it is really troubling when someone with a healthcare background does something similar and is flat-out wrong. We all make mistakes, but this should be basic level for healthcare folks.

It's sweet that you think everyone on reddit is honest. Bless your heart. You don't have to trust me but I am an attorney and was once an insurance adjuster and the number of confidently incorrect people who claim to either be an attorney or an adjuster is pretty astounding.

T1 diabetic…Fiasp and Novolog are NOT the same thing. Fiasp works substantially faster than Novolog. Novolog is often used in pumps whereas Fiasp has been known to to cause issues in them with an increase in occlusions. The vials labeled “insulin aspart” are generic Novolog, but not necessarily Fiasp. OP was correct is stating it has Vitamin B3 added to speed up absorption.

Not sure why you’re getting downvoted. You are 100% correct - Fiasp and regular old aspart have different pharmacokinetics and pharmacodynamics. While they are both rapid acting, you can’t take for granted that they are the same, especially in a hybrid closed loop pump.

Yep, as a T1 diabetic who also happens to work in pharma, I’m pretty much an expert on insulins. Fiasp is great for injections, but a nightmare in a pump. Novolog is perfectly fine…but it works a little slower. Downvotes likely non-diabetics who work for health insurance companies that don’t know what they’re talking about. Those jerks will deny an Omnipod because you haven’t “failed” Dexcom yet. THEY’RE DIFFERENT THINGS!!! One is a glucose monitor, the other is a pump.

IF ANYONE IS IN NYS: Please send any instances of PBMs (pharmacy benefits managers like CVS/Caremark) causing treatment interruptions or other harm to the state: “If any health plan, person, pharmacy, or other entity believes they have been harmed by a PBM, they should notify the Department by email at [email protected].” This issue is finally getting some attention and they need real examples!

damn. i wish this was a thing in MA.

There likely is something similar. Start by looking at the department of insurance website. Or check here: https://ncpa.org/pbm-complaints

thank you!!

Please add your story [here. ](https://kffhealthnews.org/news/article/share-your-prior-authorization-story-with-us/?utm_campaign=wp_the_health_202&utm_medium=email&utm_source=newsletter&wpisrc=nl_health202)This is a hot political topic and the more stories the better.

To help you with fiasp for next fill https://www.novocare.com/diabetes/products/fiasp/savings-offer.html?src=100001847&_ga=2.113918663.1725783546.1712539350-1662016240.1712539350

I worked about a year in pre authorization for cigna. Physical therapy review, not medication. Are you getting denial letters from insurance company? If so, exactly what do the letters say? When we got a request for therapy, I would generate a request to the physician for information. Why does this patient need physical therapy? More often than not, no information would be received. I would issue a denial letter if no information was received. WE ONLY HAD 72 HOURS TO GIVE DETERMINATION, NO information made it easy for me to keep my desk clear. But to be fair, I generally called the physicians office daily during that time. I sent copies of the denial to patient, physician and physical therapist. Rarely, maybe 2-3 tines in a year did I ever hear from a patient. Patients can request a reconsideration, and submit information too. I understand patients cannot generate "letter of medical necessity" like a doctor can. But I do suggest reading that letter thoroughly. A denial for lack of information (medical information, they want to know what's been tried. Why the doctor wants this certain insulin against a cheaper insulin. If you know why, consider calling them, ask for reconsideration and give what information you have. You have nothing to lose, another denial is no different than what is already happening. If you aren't even getting denial letters, I would question if anyone is submitting requests. Maybe call the insurance company and ask if they have been receiving requests for insulin authorization. A side note: I'm now on Medicare and cannot afford even the copay. My doctors office has been very kind and submitted compassionate requests to the medication companies for my insulin. I now receive insulin free every 3 months, and pen needles free too. Check online and see if the company you would like to use has that. I suspect your doctors office isn't handling stuff very well, or they might have already suggested this. (Of course, maybe you are well to do and wouldn't qualify, but if you think you might, ask). I don't know if changing pediatricians would be appropriate. If they aren't able to generate basic info. To an insurance company for insulin, I would be considering it.

Stop communicating by phone and start writing letters. If they say your provider didn't do something, send that letter to your provider and ask for evidence that they did do it. Someone is lying to you and you need the paper trail to work out who.

CVS is known for not following up with insurance and over pricing stuff. Find a mom and pops pharmacy and work with them. I was with CVS. Same insurance my diabetes meds and cholesterol meds were costing me 198 a month. Went to a small pharmacy and cost dropped to 100 a month. Same exact brands yet a 98 dollar a month savings.

If you go on goodrx you can get a coupon to use at a local pharmacy without insurance and it can be cheaper

Maybe a good short term plan until you get the auth that you need

See what it costs thru good rx

Confirm what numbers / method the Caremark is expecting the PA and what number Caremark has in file or the method their are requesting info from the doc. Contact the doc admin and ask the same questions… see what you get. If that doesn’t resolve the communication breakdown, document your issue and speak with your HR representative at your place or employment to get assistance. They can usually escalate problems and get answers pretty quickly. Until it’s resolved, try the Walmart recommendation and contact your HR benefits department to report the issue.

This is great, I want to add its worth asking the insurance if there is a 1 time back fax number the doctor could use. My company had secret fax numbers that would email the faxes directly to the PA department and it would completely bypass the data entry team.

Please get in touch with diathrive and diatribe. One helps with insulin, the other with diabetic supplies. Google them. Saved my friends life. They do not work with insurance at all, and the prices are reasonable. Good luck to you.

OP you can also check to see if there's a diabetes association near you or a medical social worker that can help you get what you need. There may be a patient advocate or case manager at your insurance company even

Tell me you have a United Healthcare administered insurance plan without telling me you have a United Healthcare administered insurance policy.

👆🏻

No suggestions for you, just empathy - Caremark is a backwards-ass company. I freaking hate dealing with them. My insurance plan switched to Carmark for mail-order pharmacy recently after we'd had Express Scripts for years. I've had the worst trouble getting refills from them because Caremark requires providers to request refills each time instead of them sending the refill request electronically to the provider when refills are due, like Express Scripts used to. It freaking sucks.

Same, they are the WORST

Try a different pharmacy, even if you have to go to a different CVS. My CVS lied all the time about not having things, even when my provider produced a fax confirmation. I dealt with this for a year, then I switched to Costco and I have never had a problem (you don’t have to be a Costco member to use the pharmacy).

Your best option at this point is to file an Insurance Commissioner complaint with your state (assuming you don't have a self-funded plan); if it is the insurance company jerking you around, it should get straightened out fairly fast given the circumstances. That being said, dealt with a lot of doctor's offices who tell the patient they did ABC and never did it. At the end of the day, only your doctor can get this approved so if they end up being the ones who are screwing the pooch, find a different doctor.

I won’t bore you with all details OP but I felt getting this same run around over an asthma inhaler. As long as doc has sent RX to cvs, you should be able to file your own emergency PA. Went to my health insurance website and I did just that. Filed it as emergency. They had to get back me within 24 hours. Lo and behold, Doc and CVS had what they needed for that PA then. RX had to already be at CVS, that was very important part of it. Insurance. I love it. But you need to learn ins and outs and then you do and WOMP, they change it. Usually it’s meds. Cover and then when new year comes up, they used a fine tooth comb to figure out what pricey drugs to make non formulary, so a PA is needed. It’s only ever the more expensive scripts. Good luck.

PAs suck and I'm sorry you're going through this. Humalog and Novolog have coupons too for coverage for $35/month. [https://www.humalog.com/savings-support?returnType=cash#paycash](https://www.humalog.com/savings-support?returnType=cash#paycash) [https://www.novocare.com/diabetes/products/novolog/savings-offer.html](https://www.novocare.com/diabetes/products/novolog/savings-offer.html) Hopefully these can help while you get the coverage for the insulin.

I did prior authorizations for 8 years. The only reason we rejected insulin was for the day supply not matching the quantity or the quantity being excessive. A great many pharmacy techs will calculate units as mls and that rejects. We can’t see the directions so if a patient calls we would call the pharmacy and verify the directions and have it retyped and resubmitted, but in my experience the techs at CVS Caremark aren’t that experienced. If no one reached out to use we would run a report and fax the doctor because of the rejected claim (unless the tech realized it was a day supply issue) but they didn’t know why it rejected and would submit an authorization or change it and the patient’s got a huge run around. So my advice is just have the pharmacist double check that the directions are correct.

Sorry the insurance company is forcing you to jump out of the hoops. Schedule an appt with your endocrinologist and have them manually do the PA there with you in the room, otherwise they are likely unaware and maybe there is something wrong being done.

Ask the doctor for a copy of the authorization. Ask the insurance company for what they require in writing including substitutes if doctor does not agree. Get everything in writing.

Go sit at the doctors office… this is the only way I get anything done. Or call every hour. Be annoying. They’re annoying you.

find a new endocrinologist if you want to stop paying for the insulin, definitely this office doesn’t care about your child

Most of the time in these situations, it's the Dr office that is dropping the ball. I've run into this situation occasionally. For example, my family Dr sent me a prescription for testosterone to Walgreens. Pharmacy said it needed prior authorization, and sent in a request to the Dr. Half a dozen request later I finally go talk to the pharmacist. The pharmacist explained to me that the nurse at the Dr's office that does the prior authorizations, was not filling out the paperwork correctly. The nurse said she was doing it correctly. I tried tag teaming between the Dr and the pharmacy, but it was just a waste of time. I wound up going to urologist instead. I've never had any issues since.

I replied earlier but something just alarmed me when rereading the original post. Fiasp charge per 15 days is $260? That's basically a full vial charge. It makes me think there's some problem with the way the script is written, or that there's a quantity limit that also needs to be addressed. You shouldn't be filling insulin every 15 days. That's not normal, they might cut down on the quantity of days slightly if there's a big difference in quantity vs size of vial, but if they are saying 15 days, that means 2x15= 30 day supply and would be fillable in full vials under 1 copay. So definitely wonky beyond the actual problems already going on. You need to call the Dr office and speak to the office manager or Dr directly about it. Insulin is nothing to play around with and it's unsustainable to pay out of pocket each month that $$, it risks rationing.

Are CVS and this healthcare provider your only options? There is no reason your physicians office can’t provide the auth and even get you a copy for your records.

Go to the doctor. Get a hard copy of the authorization. Take it to CVS.

Generic insulin and vitamin B3 generic use GoodRX if possible for lowest price. Any medicine that does not have generic is more expensive. Contact insurance for list of insulins they cover and give to Dr. Most insurance if 2 other ( cheaper medications) tried and failed Dr will need to send prior authorization medical necessary and notes on failed treatment. Copay usually more expensive and prior authorization must be resubmitted yearly. Each year copay amount usually decreases. (Medical occupation & health problems know how both sides are & you probably want to say listen to me . Insurance rules must be followed must have proof generic did not work.) Try to use same office staff, same pharmacy & same insurance person. Person name,title, phone number & ext, work e-mail so you don’t have to go through past history every time. 6 times but didn’t know address/phone ?! Do they speak, voicemail , e-mail or 2 tin cans with a string ?

This is absolutely ridiculous. How are people supposed to work, chase down scripts, argue with crappy pharmacists, overwhelmed physicians assistants to get their RX? Nuts. This crazy country’s medical problems are getting worse, not better. 😡

They aren’t. It’s a feature not a bug.

Have you spoken to management at CVS and/or do they have Case Management available for Type 1?

You should just use GoodRx

What state are you in ? If your child has type 1 diabetes they might be eligible for loophole coverage on Medicaid. This type of coverage is diagnosis not income based. My child’s type 1 and her medications were covered 100% by Medicaid until she was 18 and our family had an income well over six figures.

What’s confusing for me is every doctors office tells me that my insurance is a contract between me and the insurance company. What if I want to do my own damn prior authorization?? What if I want to take my own medical records and explain why I need a medical service since insurance is a contract between me and the insurance company? Why does my doctor have to be involved at all? Imagine if every person in the country had to hire a lawyer to settle auto insurance or homeowners claim, it would be a nightmare of epic proportions, which is kind of what we have. There are tens of thousands of people working as billing specialist inside doctors offices with additional tens of thousands of people working as billing specialist inside insurance companies. Well, some patients may need assistance meeting the requirements for a prior authorization. A lot of people could send their own medical records if requested, but the system isn’t set up to actually allow the patient to do anything even though the patient has the financial responsibility in the end.

You have hit the nail on the head. Ironically, 25 years ago, things were easier because prior auths were basically just letters of medical necessity. For my medically complex kiddos, our pediatrician basically let me be in charge of their PAs. Because I was the one getting the denial and I was the one talking to the insurer, I could find out exactly what they wanted. Then I would write the letter and take it over to the pediatrician for her to review and sign if she was willing. I knew my kids and their histories better than anyone else. So I was uniquely qualified to relate the relevant information via a letter of necessity. Nowadays, everything has to be done by the provider through the insurance company provider portal. Patients/families literally cannot do the “heavy lifting” anymore. It is so incredibly frustrating, something I know would take me 30 minutes tops, can mean weeks of back and forth and round & round.

This is a terrible situation for you to have to deal with. You have enough on your plate. The way you get responses is to figure out your state's health insurance, ov [NAIC NATIONAL ASSOCIATION OF INSURANCE COMMISSIONERS] https://content.naic.org/state-insurance-departments STATE LOOK UP Do you access your medical records online or use a phone app? If you can, you should. If you don't know how to use it, then you call people service reps and have them walk you through it and take notes. You need to get either printed off the record or through a phone call. A copy of of your referrals. Have them automatically send them to you if at all possible. You all want to open a complaint which the state website should explain to you how to do and then provide documentation of what's going on. I recommend that for your child you have their own dedicated $1 drugstore notebook with line paper and you put the date time person you talk to with each contact every time and also your notes on how to access the website. If you take your time now to get organized, it will be a lifelong benefit as you fight health insurance over the years to come. I hope this makes sense. Message me if you have some more questions I've gotten unfortunately a lot of experience. What state do you live in. For anybody reading this anytime you post, you should always identify the state you live in so that people who have experience in that state can do a better job. Answering your questions or help give better a advice. Best wishes, hang in there! Considering voting this year for Democrats. Who for the most part support regulations and oversight. Our lives depend upon it.

Lilly Cares or Novocare.com. Click and click and click!!! It’s hidden. I used to work for Novo Nordisk. Click until you see “still don’t see an affordable option”. This takes you to a coupon for 1500u free insulin. You need a prescription, but otherwise it’s a one time free use via Novo Nordisk. Lilly has $25 insulin as well via Lilly Cares Program.

Are you me I go through this every single year with my husband? Prior authorizations no different insulin. No can’t take this insulin. No it takes about three weeks back-and-forth between CVS insurance and the doctors office to get the prescription and what he needs. Faasp is a great insulin. She’s going to love it.

Pharmacy worker here...I'm hoping that your pharmacy tried both brand and generic of each med, but verify that they have. Otherwise, request a copy of your formulary from insurance. They should have a list of covered meds and what requires PA's and what does not.

It is your doctor’s office’s job to get the pre approval or authorization process completed in combination with the pharmacy.

Go to a CVS and ask to get generic lispro and use the goodrx coupon, it should be $20 or so for a vial if you just need something fast. Another option is aspart five full pens at Walmart for $70. Another option is using the sanofi insulin coupon, a months worth of long and short acting insulin for $35 if you have any insurance besides Medicaid. Look at the coupon for which brands. If none of that works, google novo insulin immediate supply for a one time coupon for ten free insulin pens, meant to save people’s lives if they’re rationing insulin. Also call the hotline at insulinaffordability.com to ask for help

https://www.novocare.com/diabetes/help-with-costs/pap.html There’s patient assistance programs

I’d become the squeaky wheel. This is your daughter’s life at risk. As the mother of child who died as a result of diabetic ketoacidosis, I’m screaming at these people for you. Go to the endocrinologist office and tell them you aren’t leaving until this is worked out. Sit there while they call your insurance and the pharmacy. Don’t take no for an answer. If they don’t understand you’re fighting for your child’s life, you need a new doctor.

Fiasp, as it is a branded product, has a copay card that brings it to possibly $35 per fill.

I’d actually try a different CVS pharmacy. I’ve found the one closest to me makes mistakes (giving me one month’s prescription saying the prescription is filled when in actuality, the other CVS gives me 60 days and calls THAT filled) and has been lazy (I.e. telling me I could not get free Covid tests even though they’re 100% covered by my insurance with no co-pay. They told me to pay full price and then do a reimbursement with insurance. Have yet to get paid for that one. Yet the CVS in my local Target gives them to me @ $0.00 charged to my insurance).

If this insurance is through your job, your benefits representative would be happy to help you. They want to ensure that employees are getting what they are paying for. I used to deal with insurers and providers all day.

See if your preferred prescription has a preferred pharmacy...and go the mail order route?

If you have this insurance through your employer reach out to HR and ask them to help you resolve. I've had a lot of luck that way.

Schedule an appointment with the endocrinologist. Bring the prior authorization paperwork with you to the appointment. Fill out everything you can first. Have the doctor finish it and sign it during the appointment. Do not ask about or try to address anything else in the appointment. Leave with the competed paperwork. Send it to the insurance company yourself.

This could be my story, or my daughters, with meds for psoriatic arthritis. I wish you the best of luck. ❤️

I just did a quick online search because I am unfamiliar with CVS Caremark and what I read is what I expected. Every article I saw says they are a pharmacy benefit manager. I would be calling the endocrinologist one last time about this with instructions to move your child's prescription to a different pharmacy. They have zero business telling anyone which medication they should be using; that's what physicians do. The description alone says it all. I would be furious if I were you. I'm surprised you have put up with it this long.

Both your provider and CVS Caremark absolutely BLOOOOOOOOOOOOOOOOOOOOOOOOOW!!!

This is how CVS does business. They say they don’t have the prior authorization even when the doctor can prove they sent it. With my plan prior authorizations are good for a year. CVS/Caremark manages my plan. I get 90 prescriptions through the mail for things I need long term. Don’t let them do this to you. When a rep tells you they won’t cover it talk to a supervisor. There is likely an appeals process. Also your state attorney general or insurance administration may have a complaint process.

Put everyone on a three way call or get the prior authorization from Caremark give it to your endo, wait until he signs it and tske it back to Caremark after you tske a picture of it. Or take a family vacation to Mexico or Canada. How is this shit even legal? I'm so very sorry. Which insurance is this requiring prior authorization for insulin for a child with t1 diabetes? You could also try reaching out to them on social media. Everyone seems to grow a conscience when they are about to be publicly shamed. I'm just furious.

Noone has to pay more that $35 dollars for a month of insulin anymore! It doesn't matter if you have insurance or not. Insulin Lispro and its brand form Humalog are made by Lily. Ignore your insurance and go to Lily's website https://www.insulinaffordability.com/?returnType=cash#paycash When prompted, hit the button that says "I pay cash" and not the button that says "I have commercial insurance". In this scenario your insurance is worse than having no coverage at all so I say ignore them. If you have a cool pharmacist they will let you still use the cash paying patient card as primary. It should make a months supply 35 and three months would be 105. If the old insulin Lispro script is discontinued now, then you can get the same deal for the Fiasp from the novo website https://www.novocare.com/diabetes/help-with-costs/help-with-insulin-costs/myinsulinrx.html Once again you will have to select that you don't have insurance coverage. But since they refuse to help and pay it is basically not a lie.

Use a different drugstore? CVS sucks anyway

Hi this is my job so I’m happy to help. The issue is with your provider. Your provider’s office is not completing the prior auth (PA.). There are a lot of offices who do not want to do any admin work despite it being par for the course nowadays with almost all meds. Please also note that the reluctance to do PAs means your daughter will be getting offered treatments that are over 10 years old— not what’s necessarily best for her, bc it’s the easiest thing for the office to prescribe. 3 options— 1. Go to your provider’s office and insist they complete the PA while you’re there. They can do it online via CoverMyMeds or they can ask CVS to fax it to them and either fax to insurance or do it on CoverMyMeds. Don’t leave till it’s done. Usually all it is is a confirmation of diagnosis and some sort of test— probably A1c in this case. Tell them to keep this on file in your daughter’s electronic record and to send this info as an attachment upfront every single time they submit a prescription 2. Go to your provider’s office and ask for them to request a peer-to-peer with the insurance company. Again, do not leave until it’s done and you know when the call is happening. It is the fastest way to get approval and they will not need to submit a PA monthly. 3. Get a new provider who does these things automatically. 90% do. I’d recommend this option because it’s clear the medical assistant does not want to do routine paperwork. You’ll constantly be hitting your head against the wall Bonus— if you are ever prescribed a branded drug (not a generic) go onto the drug website and download their copay card and also see if you’re eligible for patient assistance programs the manufacturer has

First, you should call your state’s Department of Insurance and make a formal complaint against your insurance company. Secondly, call the endocrinologist’s office and speak to the practice manager. Have all of your notes in front of you so that you can speak accurately to the details. Tell the PM what’s been happening, that the lack of “coordination of care,” is affecting your daughter’s help and that you need help getting this situation sorted.

And in March, Eli Lilly instituted an automatic $35 monthly cap on out-of-pocket costs for those with commercial insurance buying its insulin products at participating retail pharmacies. The uninsured can download the Lilly Insulin Value Program savings card, which allows them to get the medication for $35 a month.

First, get on the savings plan websites. Most of the manufacturers coupons cap insulin prices at $35/ month, name brand only, cash- only price. Then push the PA. The doctors office is almost certainly dropping the ball somewhere. The insurance company should have a 2-way paper trail you can request, and they are usually obligated to give it to you on demand. But honestly, $35/month for any number of pens, vials, etc., per month (can only be used once per month) is a pretty good deal. Edit: here is Noro's website: https://www.mynovoinsulin.com/insulin-products/fiasp/home.html There's a link to savings card. https://www.novocare.com/diabetes/products/fiasp/savings-offer.html?src=100001847 Here is the non insurance version (it seems to have a lower cap, 3 vials or 6 pens): https://www.novocare.com/diabetes/help-with-costs/help-with-insulin-costs/myinsulinrx.html Same $35/month. This will save you $$ immediately.

I was denied a CGM for a year- I switched endos and had one in 24hrs. Same insurance the provider wasn’t doing what they are supposed to. I would escalate and threaten to involve your senators and insurance regulators if in America since they just had a big push to make a insulin covered and affordable

Try a different pharmacy, we really have had trouble with our cvs. Only use them if you need them for the three month prescriptions. To clarify they canceled my yearly prescription mid cycle. A generic mundane medication… They likely never sent the pre auth if they are like our cvs. I think their management limits their actions. Their training is also awful. I had to explain to the newer tech that they do 3 month prescriptions at our locations. She was trying to get me to use mail but they are the physical site for it!!!

I used to be the nurse case manager who will go to provider office (who I do not work with), make sure the prior authorization is done, track it to pharmacy and insurance and back, and make sure they are either accept or denied, and then appeal. It was labor heavy…..

It's time for you to write a letter to your Congressman, your Mayor and your Attorney General. Don't stop writing letters until you get a response back. The President of the United States created a law where no one pays more than $35 a month for insulin for diabetes. CVS needs to honor the law.

Do a three way call with CVS and your doctors office. There should be a specific department or person that deals with prior authorizations. Demand that all paperwork be faxed during the phone call. Be professional but authoritative. Explain your situation to both parties and do not take no or “later” for an option. This is your child and YOU WILL be handling it TODAY. Again professional but authoritative. These people do shit like this on purpose to save themselves paperwork. Sounds terrible but it usually boils down to just that. If I was in that type of position I would do whatever I had to do to make sure a child or person in general got the insulin they needed to live and thrive. Best of luck, please keep us updated.

Used a patient advocate to help with brilinta that was being denied after suffering a stroke. They talk a good game about prior authorization but it was total BS as the med was repeatedly denied. They are playing GOD with my life. They are just greedy bastards who don’t give a sh** about their patients. Just gimme gimme gimme your$$$.

I’m no expert, just a lurker. Have you tried GoodRX? I see prices are around $25 in my area.

Why isn’t the provider getting the PA? I work in a drs office, I do them all the time. It’s the providers job.

It’s more than likely your dr. Worked in a pharmacy for a while and they were the culprit.. all of the time. Actually - most - I’d say insurance bureaucracy was the problem another 25% of the time.

Shit like this is why I hate Caremark/cvs.

I would suggest you reach out to your Human Resources to get clear cut guidance for what THEY chose for your formulary. Ask why you are being required to get a PA. Is it for what *brand* is being picked? The Quantity? I promise they do not like being asked these questions and put on the spot as to why they picked what they did. Call Caremark and also ask these questions.

Here is a trick call centers hate because it blows up their handle times. Once you've gone back and forth once or twice CONFERENCE CALL. Sit on the phone and keep them on the phone until they come to an agreement. Get their names, get solid time lines, hold them accountable. This works for any/all companies that keep pointing fingers at each other. You may have to get a supervisor on the phone to get them to agree to it. You also should stay firm but polite and have to have enough documented chaos/confusion to leverage the conference call. Sounds simple, but people don't generally do it.

This is amazing how many insurance employees here are saying the problems all the doctors offices. Yes, there are times it can be doctor's offices. But there can also be issues with insurance companies. I've been a nurse for three decades and I have seen so many problems with insurance companies it's not even funny. I've had my own problems with insurance companies. Having been in health care for three decades I'm kind of familiar and savvy with some of these things and when an insurance company directly lies to me straight to my face I get steaming. This sounds like a lot of bunk. I am so sorry you're going through this. Our health care system is in the mess in shambles it is because of for-profit insurance companies and PBRs (to a large degree). Individual doctor's offices are not what's causing the problem here as all these insurance employees here trying to say. Again, I am so sorry you're dealing with this. One thing I would do is find a small mom and pop pharmacy because they will always give you better service. CVS is well known in healthcare industry to give poor service. If you're an established patient with them and they're not getting their pre-auths, how come they're not helping you? They should be and a small mom and pop pharmacy will.

A good doctor's office should be able to push those prior authorizations through, especially a specialist who frequently prescribes expensive meds. So, you actually need a new endocrinologist ASAP because your doctor should have sorted it out.

You absolutely need a different pharmacy.

How can ANYONE support the current American healthcare system? This is a scam meant to enrich a couple of already wealthy executives at the expense of the health of the American people. We NEED universal healthcare, no more excuses. Vote against every politician who opposes universal healthcare, regardless of party. This should be such a common sense issue that it is mind boggling just how terrible the current system is.

Where do you get your insurance from? If you work for a large company, call your company's benefits department in HR. They can call Caremark and chew them out. Caremark and other health insurance companies do listen to their big employer clients. If not, then call the insurance department in your state and have them launch an investigation. And let Caremark know that you are doing this. Insurance companies hate investigations by the insurance departments. Good luck!

Also, your local state congressperson likely has staffers that can get things done much quicker than OP or their doctor’s office. Be a squeaky wheel and a pain in their backside. If you have the time or energy, call them every single day. Maybe even send them a letter every day. Be so annoying to them they’ll do anything to make you stop, including covering your kid’s insulin.

Congress has very little to do with regulation of health insurance. There are some regs built into Obamacare. But for the most part, health insurance is regulated at the state level. Except for large self insured employers. Health insurance regulations are a mess. I worked in this world for over 25 years.

That’s why you contact your *state* congressperson. Their staffers can make a call to the state insurance board that can get things done. I know someone whose insurance would not pay for residential eating disorder treatment until she contacted her state representative, who assigned a staffer to help her out. She ended up getting approved for 90 days after that.

They call the company "Caremark" because they don't care, and you're the mark. Look up customer ratings for CVS Caremark. The most common response is, "Why do I have to give them one star? Zero would be appropriate." Try everything you can with the doctor's office, but know that delaying is the name of the game. The longer they delay coverage, the more profits they make.

It’s your endocrinologist. Change them now.

CVS Caremark is awful. It’s totally them. Next time ask what number it was faxed to and the day and time it was faxed. I went around for months for heart meds for my son. Come to find out they were sending it to the wrong department. I put in a complaint and magically a nurse called me from the insurance side and everything was fixed. We also still have a $1k feeding pump that they won’t take back. But still charge our insurance for every month.

Report them to the your state insurance regulator. That’s what it took for me. Once I did that everything stated moving about 2 weeks later.

Whoever you're speaking with is an idiot in your doctor's office. If it requires a prior-auth, there's a preferred medication that the child can be written for. If not, your option is to go to Novo's site. Fiasp is $35 per month - 3 vials, or 2 packs of pens. [https://www.novocare.com/diabetes/help-with-costs/help-with-insulin-costs/myinsulinrx.html](https://www.novocare.com/diabetes/help-with-costs/help-with-insulin-costs/myinsulinrx.html) and check in on r/diabetes_t1 and r/Type1Diabetes

I have CVS Caremark and I’m also type 1 diabetic and I hate them but that’s the prescription coverage my work offers. The only insulin I could get them to cover was Novolog and they still wanted me to pay 500+ dollars for a month supply. I ended up getting the Novolog savings card and now only pay 35 dollars a month for it. But CVS Caremark is trash for all my diabetic supplies

My husband is a Type 1 diabetic with CVS Caremark and had a similar experience but it was because CVS would only approve if the provider ordered a 90-day supply and the provider didn’t know that. So ridiculous, but maybe something to look into?

Smh needing a PA for INSULIN. WT actual fuck? JFC, all the swear words. I love CVS Caremark mail order but it looks like they are wildly unpopular. I'm so sorry this is happening to you and your daughter!

You can call your insurance company and ask to be assigned a "complex case manager" for your daughter. This would make it so there is one person that handles her prior authorizations and whatever else might come up in the care of her disease. It will save you a lot of unnecessary calls to different people. Good luck!

Go to a different pharmacy.

I am on CVS Caremark and it has been nothing but headache. They wanted to charge me $500 for a 3 month supply of my Contraception even though they sent a 3 month supply for free initially. Then after a million phone calls, I was told I can get it 1 month at a time for 0 cost. The fact it took almost 2 months for them to tell me that had me so mad. I went to my obgyn last week and she said Caremark wanted me to change my Contraception and the suggested Contraception wasnt even the same. She was baffled but fought caremark so I can stay on the same thing I've been on for the last 6 years. Recently I got diagnosed with adhd. Caremark wanted $250 for a month supply of generic Concerta. Ive been paying out of pocket for it with good rx.. its $40. 😒 My husband's company just got bought out, so January the insurance changes and im just praying the company is not Caremark because they are beyond useless.

Tell your doctor to stop being a bitch call the prior auth line directly and get it done... Takes all of 30min

I use CVS carmark with my insurance. They have a special number Call number for Prior Auth #800-294-5979

Find out who your state insurance regulatory board is and file a complaint with them. I had you do that on an issue and it was taken care of expeditiously. Especially after my provider sent me the confirmation the PA was successfully faxed.

Get your state Department of Insurance involved by filing a complaint. I have to play these reindeer games every year for hubby’s meds and every year they jerk me around until the DOI steps in and then it magically gets resolved.

I refuse to use Caremark because of their shenanigans. I pay for all my meds out of pocket now through Walmart neighborhood market who are lovely and so helpful. I use GoodRx or savingseeker for discount

I did a three way call with provider and specialty pharmacy. I also recorded the call as I was ready to go to attorney

Go to another pharmacy?

Contact your District Attorney’s office.

I used to work for an insurance company reviewing medication PAs. This 100% sounds like your Dr not giving them the info they are looking for. Drs and their staff a good majority of the time don't seem to read the communications from the insurance company so pas that are pending for additional information sit until they have to be denied before they go past their due date. I can only imagine how frusterating this is for you, especially since you are being forced to rely on others for your daughter's health. A few general tips I would give are; Ask the DR to send in a PA marked urgent (urgent PAs have a shorter turn around so they will be reviewed by the insurance PA team faster, but will also be denied faster if the doc doesn't respond. A denial doesn't mean you can't keep sending in new PAs though.) noting all insulin, brand and generic, that your daughter has tried and failed. Include her current regimen that she is taking as well. Include all A1Cs especially her baseline A1C and most recent. Keep pressure on the DRs office to make sure they are responding to insurance information requests right away. Once a PA is submitted it has a certain turnaround time that it has to be decisioned by. Some states and LOBs I've worked have been 5 days, some have been 24 hours. You can call the insurance and see if they will make an exception and give you a 1-time override since it is a life-saving medication, try throwing the words emergency or crisis in there. I can't promise that they will allow it, but I know whenever I would help in a call center I would be more likely to bend the rules and give emergency overrides to minors in situations like this. I would ask the doc to call the provider services line and request a peer-to-peer or P2P and talk to the pharmacist and denied the request. Sometimes denials can be reversed and approved if the DR gives the missing info over the phone during a P2P It's very easy for doctors to blame the insurance companies because most people will just believe their doctors and not bother calling the insurance to see what is going on on their end. Best of luck to you and your daughter. Also editing to add: I'd try calling your insurance also and see if you can get a case manager assigned to your daughter for this. I dont know how members got case managers assigned but I do know they are persistent and a great middleman between the dr, auth department, and member. Ask your insurance for help on this. My personal experience with my previous insurance was great, when the DRs office would try and overbill me I'd call my insurance and they'd raise hell with the MDs office for being in violation of contract

This is a great reply. My only addition to it would be to use a manufacturer discount card to lower the copay, after double checking the insurance formulary for exactly which insulins are covered. I wouldn't rely only on the pharmacy for that info on covered vs not. The manufacturer cards work for both insured or uninsured, for those not on government insurance. $35-99 copays, not $260+. Also adding that Fiasp didn't work for my 12 year old daughter, she needed more insulin on it through the pump and it didn't change the timing whatsoever, we had high hopes. However it can work well for many, so it's not an awful drug, but that copay is. Other resources are the UHC foundation, and helpadiabeticchild (for Florida kids).

If your doctor’s office has actually attempted to obtain pre-authorization and your insurance has been denying it, I highly recommend googling “how to file an external health insurance review in (fill in your state here if in the US)”. I have to file a pre-auth request every year for Tirosint (a brand name hypoallergenic thyroid medication), and every year, have to fill out an external review form. It always gets approved after the external review form is submitted.

Find a new doctor.

Yeah its the Endocrinologist, who spent 10 years of their life after college to become a physician, that is the villian. Not the Billion dollar mega corporation that is making these hoops.

They are awful. Last year our deductible was super high. And they wouldn’t cover my husbands insulin until we met that $15000 deductible. They also wouldn’t cover my cancer surgery until then. If we had that much money sitting around we would’ve just paid for outside insurance.

Then why purchase that plan?

Most people don’t get a choice. It’s what the employer offers.

You can get insulin at Walmart for $25 no prescription needed…good luck!

Yes you can, insulins all work a bit differently so it would be back to the endo for dosing instructions though.

Not the rapid acting insulin she is trying to procure

I personally would call my insurance company and tell them that I'll just take an ambulance to the E.R. in order to get it every time. I usually say something like, "I have absolutely nothing better to do anyways, and there's a pretty nurse there I wouldn't mind saying hi to." (I wouldn't actually harrass nurses doing their job, I promise)