Insurance Blues

The players includes
Medtronic – the makers of my new pump/sensor combo. The one I mentioned was changing my life just the other day.
OptumRx – My insurance company for prescriptions and mail away pharmacy. This is very confusing because I also have Blue Cross Blue Shield, who apparently isn’t in charge of prescription insurance but somehow meddles in my coverage anyway.

I’m in the process my next box of sensors. Without insurance, they are $553 for one box. With insurance, they are $80 a box. One box lasts about a month.

I called Medtronic the other day to order my next box. When they ran the order through OptumRx (the prescription insurance), my request for a 90 day supply was denied. I could get ONE box for $80.

I asked them to please put the order on hold while I get in touch with OptumRx to see what’s going on. Why can’t I get a 90 day supply? In my online profile for OptumRx, where I can see all my meds that get cleared through them, there is an order for Enlite Sensors. Three boxes, $160. That’s $53 a box instead of the $80 I’d pay if I bought just one box. Nice little bit of savings.

I call OptumRx to discuss and they tell me they need is a prescription from the doctor for them to fill the 90 day supply order and that yes, they have them in stock (which surprised me because I’ve heard the sensors are on backorder).  I’m also told that if the doctor claims I need four boxes for a 90 day supply, I will still only pay $160. Sweet!

I emailed my doctor to request that she send in a prescription.

Now, I am simplifying this story, really, because in truth there were multiple emails to my doctor (poor woman) in an effort to “phrase” the prescription correctly. It seemed like it needed to be very specific.

When I check-in with Optum to see if they got the order, they tell me we see that the doctor sent the prescription to Medtronic, but not Optum’s mail order pharmacy.

I go back to the doctor and email her again, asking that she send the order to Optum, to which she replies “I hope this is the end of it. I have never had to send a prescription anywhere but to Medtronic!”

The next day, I’m glancing on Facebook and notice a post from someone in the 670g support group I follow (people who use the same pump system as I do) asking “I just went to order my sensors and they told me they are backordered. ‘Anyone else have this problem?” To which someone replied “Which sensors? The Guardian 3 or the Enlites?”

All of a sudden I realize that the sensors I saw listed in my OptumRx profile were the wrong sensors!!

I get on the phone with Medtronic for clarification “The 670g system uses the Guardian sensors, right? Not the Enlite sensors?”

Correct.

Great. I hang up and call OptumRx again. They connect me with a pharmacist who tells me that they will see if they even carry this newer sensor (likely not since they are on back-order), and when they find out, they will see if they can simply change the name of the sensor on the prescription and fill it for me.

The next day (today) I get and email from OptumRx telling that they were unable to process my order.

Back to the beginning.

I call Medtronic to ask that they release the hold that was put on the sensor order from a week ago and please process and send that one box to me. $80 a month is fine with me in exchange for how much better I feel.

To my disappointment, but not my surprise, I’m told “This needs a prior authorization from your doctor”.  An item that was cleared through insurance two weeks ago is no longer accessible to me.

I explain to the representative about all of the back and forth, and she explains that they are going to get to work at their end to figure out what’s going on.

I don’t know if this current issue is simply confusion between providers, or if this is a result of the fine print in Boston University’s Blue Cross Blue Shield plan denying coverage of glucometers. Since a Continuous Glucose Monitors (my sensors) are essentially glucometers, they fall under this exclusion. I know because when speaking to a Blue Cross Blue Shield rep a few weeks ago, he shared the above information about the exclusion with me but added “But I see in a past conversation with you, we told you it was covered, so we’ll work something out”.

Perhaps it will not be something that can be “worked out” without more phone calls, paperwork, patience, piss and vinegar. How BU can deny people a device that helps them stay healthy, a device that they need to have, either in sensor form or a basic glucometer form, is beyond me.