My Blue Cross Blue Shield health insurance company who charges me $1,235 a month, just informed me that they would no longer cover my Humalog insulin for my insulin pump in 2018. This news comes with a $565 increase in my monthly premium, starting in the new year.
The pharmaceutical companies contract with the health insurance companies based on volume and rebates. The subscriber base (insulin volume usage) gives them the negotiating metrics they need when they want to increase their profit margin and lower their cost liability.
Novo Nordisk set a precedence in 2000 when they offered to private label their insulin for Walmart. At that time, no branded insulin had such a unique strategic partnership. Since then Walmart switched insulin companies and used their established lower cost basis as a bargaining chip to successfully close a different deal with a Novo Nordisk competitor, Eli Lilly. In 2010, Walmart started co-branding the Humulin ReliOn insulin.
The pendulum swings back and forth with all the insurance companies, and the insulin manufactures. However, in your case, if you can prove that the insulin you use is medically necessary, provides you with better blood sugars and less hypoglycemia, it is worth petitioning an appeal and your right to appeal a denial from an insurance company. Be aware that it is routine for insurance companies to deny your first appeal.
Reach out to your physician and their staff to help you argue your case; convincing the insurance company to make an exception for you. In my experience, appealing an insurance company’s denial takes at least three appeals.
I have a friend that experienced the opposite situation with his insurance company. His insulin was switched from Novo Nordisk to Eli Lilly. He shared with me that he had better blood sugars with his Novo Nordisk insulin. I called Novo Nordisk on his behalf to see if they had a recommendation on how to get his insulin covered by his insurance, but they did not. He chose not to challenge his insurance company.