Health Insurance 101: 3 Things You Should Know When Switching Meds
You may need to switch your type 2 medications at some point in the year. If this happens, it’s important to take the proper steps after you and your doctor have determined that this new treatment plan is best for you.
For example, if your doctor recommends one type of insulin over your current one, you may run into trouble if the new insulin they recommend is not on your insurance formulary. A health insurance formulary is a list of medications covered by your insurance—also called a drug list.
In this guide, we highlight the steps you should take when switching type 2 diabetes medications to help ensure they get covered and what to do when insurance still won’t budge.
First thing’s first: don’t wait to start your investigation
Don’t wait until your prescription runs out to start this process. Ensure that you have enough of your current medications to cover you until you can get your new medication. Investigate how much your new drug will costs you and whether insurance covers it as soon as you and your doctor agree on a new treatment plan!
That way, if you run into any issues, you can come up with a plan B and still feel comfortable knowing you have enough medication in stock—more on that below.
Steps you should take when switching type 2 diabetes meds mid-year
First, review your health insurance policy. Reviewing your policy should be the first step you take to see whether a new medication is covered. You can check your policy on your health insurance website, by calling your insurance’s customer service line or by leaning on your human resources (HR) department or diabetes health care team for support.
Second, if the new treatment is covered, you should investigate how much it will cost by reviewing your plan’s formulary or calling a representative at your insurance company. If the exact amount insurance covers remains unclear after you investigate, call your HR department, pharmacy or health insurance to gain clarity. They should be able to help! (You shouldn’t have to be the health insurance expert.) Finding this out will help prevent unprecedented costs at the pharmacy counter or through your direct medical supplier.
Third, remember that your out-of-pocket costs will increase if the new treatment is on a different “Drug tiers are a way for insurance providers to determine medicine costs. The higher the tier, the higher the cost of the medicine for the member in general.” (Humana)prescription tier. Determine whether this new treatment will require prior authorization. Your pharmacist can also price a drug with your insurance before you fill it. You can also ask your pharmacist how much a prescription will cost without insurance. In some (rare) cases, it may be cheaper not to go through your insurance and pay out-of-pocket or use a health savings account (HSA) or flexible spending account (FSA).
Remember: you can always file an exception request
If after speaking with a customer service representative at your insurance company or browsing your health insurance website, you find the issue lies in name-brand coverage, see if any generic drug equivalents are covered.
You can determine if your insurance will cover generic equivalents by following the same investigative process mentioned above: call your insurance, browse your insurance website, talk to a pharmacist, or enlist the help of a patient advocate at your health care provider’s office. All of these people and tools can help provide a clear understanding of whether to switch to a generic.
If you still find that the new medication isn’t covered after exploring these routes, you should discuss the pros and cons of staying on your current treatment with your doctor to see if it’s genuinely worth switching and pursuing an exception request. Whenever a treatment is deemed medically necessary by your doctor, you can request an exception.
Get the steps to file an exception request here.
Lean on Beyond Type 2 health insurance resources to strengthen your understanding of the health insurance marketplace, get answers to FAQs and learn more about how you can optimize your health insurance plan to thrive with diabetes.
Editor’s note: Information in this resource is derived from a health insurance guide originally created by JDRF, an active partner of Beyond Type 1 at the time of publication. It has been edited to suit the needs of the type 2 diabetes community.