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Insurance Company Switch Your Medication? Fight Back

By Timothy Hay and Jeemin Kwon

Did your insurance or pharmacy switch your medication, without your medical professional knowing? This is called non-medical switching. Learn what you can do about it

Finding the most effective medication is a cornerstone of diabetes care. Ideally, the process includes the medical professional and the person with diabetes working collaboratively. But for better or for worse, insurance companies also have a say in the matter.

A controversial practice, non-medical switching, occurs when your insurance company forces you to switch medications – e.g., by dropping your prescribed drug from the list of covered medications (called a formulary) or by making your co-pay prohibitively expensive. It gets its name from the fact that the switch is not decided by your healthcare provider.

Having your medication switched – especially if your prescribed treatment is working well ­– may be upsetting, particularly when you aren’t notified in advance and you’re surprised at the pharmacy. Though switching to a different medication that is covered may have no impact for some, it can also be harmful to others (see here for some sobering statistics on the medical and societal costs of non-medical switching). In particular, for people with diabetes on insulin, switching to a different brand can sometimes result in unexpected lows or highs. 

Fortunately, if an insurance company switches your medication, there are actions you can take to get the decision reversed. This article explains the different ways to do so.

When is it worth fighting a non-medical switch?

Some medical professionals believe that switching between rapid-acting insulins (mealtime insulin) like Novolog and Humalog does not pose a huge issue. Of course, if you were using a certain kind of mealtime insulin because you’ve had a bad experience with a different kind in the past and are switched to it, getting this decision reversed is doable and recommended. This is also true of any diabetes medications, like GLP-1 agonists.

Note that there may also be a more meaningful difference between mealtime insulins if you’re using an insulin pump as opposed to injections or a pen. When it comes to long-acting insulins (basal insulin) like Tresiba, Lantus, Levemir, etc. you may have a stronger case for having a preference because the timing of the insulin action differs more for basal insulins than mealtime insulins.

According to one diabetes clinic we spoke with, if you have been stable on a medication for more than four years, an insurance company will rarely deny the request to switch back.

Keep in mind, however, that even if your insurance company decides to “cover” your original medication, it can result in higher expenses, as it is within its power to provide less coverage than its preferred medication.

Because appeals processes can be lengthy, it’s important to notify your diabetes medical professional as soon as you can if your insurance company switches your medication. Your medical professional can offer advice on how to change your dosing amounts. 

In the meantime, if you are set on using your old medication, look to see if there are co-pay cards available.

Initial Steps to Undo Non-Medical Switching

1. Request the original medication

If your medication has been switched, your first step is to contact your insurance provider and request that the original medication be reinstated. Many insurance call centers are open 24/7.

Your insurance company may tell you that your medical professional needs to fill out a “prior authorization” form. A non-medical switch means that the insurance company decided the two medications are interchangeable (even if they are not). Therefore, a prior authorization request, which outlines the medical necessity of a certain therapy, may be sufficient to reverse the decision. A prior authorization request must be submitted through your medical professional – you cannot submit one on your own behalf.  

If your medical professional is open to this, request that “99 months” is put on the form instead of “12 months” so you don’t have to go back every year for a prior authorization.

2. Ask for a “peer-to-peer” evaluation.

If requesting the original medication does not work, a “peer-to-peer” evaluation may be successful. In a peer-to-peer evaluation, your medical professional will speak with another medical professional associated with the insurance company about why the service or therapies are in fact medically necessary. These can sometimes clear up the denial without requiring an appeal. The insurance company may have a decision within 24 hours, but it’s helpful to check with the insurer about its timeline if not.

Going Through the Appeals Process: An Internal Review

If a request to reinstate the original medication or the peer-to-peer evaluation is denied, you can then request an internal review where the insurance company must complete a fair and thorough review of its decision, and explain its reasoning in detail.

To request an internal review, take the following steps:

Step 1: Start a file to collect all documents you receive from the insurer, including the denial letter from the previous attempts (called a determination letter). This will include your insurance policy and the insurer’s “medical necessity criteria,” which outline the rules the insurer must follow for determining whether a treatment or service is necessary for your specific condition.

If you don’t have all the necessary documents, including the instructions or forms for requesting an appeal, call the insurer’s customer service line and request that these documents be sent. The insurance company’s website or your insurance card will list the toll-free telephone number to call.

Step 2: The determination letter should be accompanied by an Explanation of Benefits document. Make sure the decision wasn’t made in error; common errors are use of the wrong code, insurance ID number, or date of service on a claim form. Learn as much as you possibly can about why your insurer has decided to switch your medication. Don’t hesitate to call the insurance provider’s customer service office to request more information about the denial.

Step 3: Call your medical professional’s office as soon as you’ve made the decision to request an internal review by the insurance company, because there may be staff there who can help with the appeals process. They can explain how to fill out the forms to request an appeal, write an appeals letter on your behalf, or even handle the appeals request themselves.

Follow up regularly with your insurer, and write down the name of every representative you speak to about the appeal, the date and time of each conversation, a confirmation phone number for the call, and a summary of what was discussed. If your medical professional’s office cannot write an appeals letter on your behalf:

  • Click here for the elements your letter should contain

  • Click here for a sample appeal letter

Step 4: If you have blood glucose data from a blood glucose meter (BGM) or a continuous glucose monitor (CGM) and can show that the change negatively affected you, it can’t hurt to include this in your appeal and it may be helpful.

diaTribe tip: The Explanation of Benefits document you received should explain how to appeal the decision (make sure to call the insurance provider if you still have questions).

If your insurance company conducts an internal review and then informs you that it is sticking with its decision to switch your medication, don’t give up. The internal review is just one of several steps you can take to get your prescribed medicine reinstated. And, some insurance plans allow you to request multiple internal reviews. If the internal review does not go your way, your next step will be to request an external review of the decision.

3. The External Review

If the insurance company denies your appeal after conducting an internal review, you have the legal right to take the appeal to an independent third party for an external review, which means the insurance company no longer gets final say for approval of a medication.

Your insurer’s final determination letter denying your appeal must include information on how to file for an external review, as well as the time frame in which you must make your request (usually within 60 days). You can only file for an external review after completing the internal appeal process, unless it is medically urgent– then it’s possible to skip this step. Insurance companies in all 50 states must participate in external review, but they have different processes.

An authorized representative may also file an external review on your behalf by submitting an Appointment of Representative Form. In some cases, your medical professional can serve as an authorized representative, although some insurance providers prohibit this. Your medical professional, however, might be too busy to file your paperwork as quickly as you might like. A friend, relative, or attorney could also serve as an authorized representative.

Standard external reviews are typically decided no longer than 60 days after receiving the request. Once the external reviewer makes a decision, your insurance company is legally bound to accept it. 

For more information on appealing non-medical switching, check out this resource from DiabetesSisters.

This article is part of a series on access that was made possible by support from AstraZeneca. The diaTribe Foundation retains strict editorial independence for all content.

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