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A Different Kind of Disaster

Jan 17, 2017

When we think about disasters, we usually think of the outcome, a poor health outcome. We don’t always think about the journey. The journey to poor health outcomes are many. Today I am reminded of not having the insurance coverage for the correct medication. Without it, one can have a disaster,  poor diabetes management. The consequences of that, as well as the disruption to running a smooth office.

Woman, 48 years of age, newly diagnosed with type 2 diabetes and obese. A1C 9.3%, 2-hour pp 253. Was already on metformin 1,000mg twice daily when we first met. Reported huge appetite. Other than that, stated she felt fine. Taught a low carb meal plan, started on low-dose daily GLP-1 and low-dose SGLT-2. Samples were given. Came back in 2 weeks. Weight was down 8 pounds, 2 hour pp 101. Stated appetite was well controlled. Was very pleased with plan. Ordered the medications at her pharmacy to find out neither is on the plan. For the GLP-1, in order for the daily GLP-1 to be covered, patient has to try another, long acting GLP-1 first. If she fails on that, then the insurance company will consider covering the present daily GLP-1. Same for the SGLT-2. The sample given is not the brand covered. Patient has to try the payor’s recommended brand first. Thus far this whole issue has included our office staff to try for a pre-authorization, which was denied. The patient is upset because she feels she is doing so well on her present treatment she does not want to change brands. I’ve had a discussion with the patient, but she requests an appeal, which from past experience I know will be denied. She insists her family member has won an appeal..on and on it can go. I return to the office tomorrow and will look into it. I am reminded to always check patient’s formulary before even giving a sample. This can save a lot of time, trouble, stress to the patient, staff and all.

Lessons Learned:

  • Choose covered medications. Whenever starting a patient on a new treatment, always make sure to check to be sure the medication is covered by patient’s plan even before giving a sample.
  • For uncovered medications, explain to the patient that the medication is not covered, and the cost of the medication. If there are alternatives that are covered, discuss with the patient from early on so they are not surprised and disappointed when changes need to be made.
  • Plan changes. Many insurance companies change their formularies, especially at the beginning of the year. Let patients know this too so they are not surprised and disappointed when this happens. Let them know early on there are different brands in the same class to choose from.
  • Doing the above not only helps the patient with a smooth transition, but also the office to run in an efficient manner.


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