What to Do When Insurance Switches Your Medications
Your medication is working for you, but your insurance company no longer covers it. Here’s how to handle the situation if it arises
Chris Plourde liked the long-acting insulin that she took to manage her type 1 diabetes. She had been on it for about 14 years and saw no reason to switch to something else. Her health insurance provider had other ideas.
“Three to four years ago, they just stopped covering it,” says Plourde, 39. “They wanted to switch me to another insulin, but I was nervous trying something new because I had my A1C where I wanted it to be.”
For the next few years, she paid about $300 a month out of pocket for her preferred insulin, a steep hike from the $80 co-pay it cost when her insurance still covered it. Eventually the price was too much for Plourde. In 2018, she began to take the insulin her insurance provider preferred, the same type of insulin from a different brand.
“I thought, ‘new year, new insulin,’ ” she says, with a half-hearted laugh that suggests resignation more than humor. “My blood glucose went up, and I had to check it more often to be sure I didn’t go too high or too low. It took a month to get to the right regimen.”
Physicians routinely change their patients’ medications when the drug they first prescribed doesn’t do the job. What Plourde experienced was different. Called forced nonmedical switching, it occurs when an insurance company changes its coverage of certain medications so that consumers must bear more of the cost themselves, or when it simply stops covering certain medications in favor of less-costly alternatives. And it occurs a lot.
“It’s very common, and it’s a source of frustration and concern,” says endocrinologist Robert Gabbay, MD, PhD, chief medical officer and senior vice president at the Joslin Diabetes Center in Boston and a member of Diabetes Forecast’s editorial board.
As a registered nurse, Plourde sees a lot of concern among people who lose access to their medications. “That’s especially true with parents, who worry when their child gets switched,” says Plourde, who practices in the Nutrition and Wellness/Diabetes Education Department at UP Health System in Marquette, Michigan. “They want what they’re comfortable with.”
Switching to a new medication or diabetes tool can affect more than your ability to manage your blood glucose; it also may increase your stress. “The fear and anxiety, which is real, is whether this new insulin will have a different effect on my control,” says endocrinologist Matthew Freeby, MD, an assistant professor of medicine and director of the Gonda Diabetes Center at the David Geffen School of Medicine at the University of California–Los Angeles. “Am I going to have more hyperglycemia? Am I going to have more hypoglycemia?”
Plourde is no stranger to the emotional ramifications of sudden switches. Her insurance company stopped covering her insulin pen needles, requiring her to use a syringe and vials instead. That happened without warning. “One day I asked my mom to pick up my pen needles while I was at work,” recalls Plourde. “She called me and said, ‘They’re not free. They’re $90.’ ”
The cost went beyond financial. Insulin pens had allowed her to inject discreetly in public, which she valued. The switch to syringes changed that. “I am pretty open about my diabetes, but it took me 25 years to get to that point,” says Plourde. “The vial and syringe made me feel less normal.”
Using a needle and syringe makes keeping up with her insulin treatment more difficult on busy days at work, leading to the occasional missed dose, and it also makes it harder for family members to help when she gets sick. That’s a problem she never had with pens because of their ease of use. While she has adapted, she remains angry.
“Something I was comfortable with that fit in my lifestyle was taken away,” says Plourde. “I feel that there would be far fewer people suffering from diabetic complications if we had a right to pick what works in our lifestyle.”
According to a 2017 survey conducted by the American Pharmacists Association, more than 75 percent of the time, people learn about medication coverage changes when they arrive at the pharmacy. And the majority of surveyed pharmacists said that there’s often a delay in getting the new medication; in some cases, it may take three days or more.
America’s Health Insurance Plans, an industry trade group that represents health insurance providers, did not respond to multiple requests for comment on the practice of nonmedical switching.
It’s not just insulin that gets switched. Blood glucose meter and test strip brands, as well as other types of diabetes medications, also are subject to nonmedical switching. Gabbay sees it frequently with GLP-1 receptor agonists, which boost insulin secretion in people with type 2 diabetes. A common scenario: Your insurance discontinues coverage of your once-weekly injections in favor of less-expensive daily injections. That extra burden may make it harder to stick to your self-management routine. “If you have to take something every day, you’re likely to miss some days,” says Gabbay.
For a study published in 2018 in the journal Current Medical Research and Opinion, researchers surveyed 451 people with type 2 diabetes about their experiences with switching. One in five had been told by their health care provider that their blood glucose levels were somewhat or much worse than they had been on their previous medication. Nearly the same number reported that they had to check their blood glucose levels more often after the switch, an additional burden to the already cumbersome routine of self-management.
Nonmedical switching also happens with drugs for other types of ailments. For example, among people with diabetic neuropathy, pain medications may be switched without warning. Kim Maurer, MD, medical director of the Comprehensive Pain Center at Oregon Health and Science University in Portland, estimates that 30 to 40 percent of her patients will be switched from one pain medication to another at some point during treatment.
For example, people who took pregabalin before July 2019, when its generic version was approved by the FDA, often got switched to the less-expensive gabapentin. Both are considered first-line treatment options by the American Diabetes Association for pain caused by diabetic neuropathy, but some people do better on pregabalin, which is marketed as Lyrica. “They can go through a rough time when they switch,” says Maurer.
Some medications that Maurer prescribes to her patients with diabetic neuropathy do more than control pain; they also serve as mood stabilizers. Losing access to such drugs can have multiple consequences. “They are probably going to get more depressed or anxious if their pain gets worse,” she says.
The Right Stuff
By now, you’re probably wondering: If this happens to me, what can I do? First, understand that if you get switched from one medication to another, you may do just as well on your new medication as you did on your previous one. “You’ll know if there’s an impact within a matter of days,” says Gabbay. “And there may be no impact.”
Freeby says that switches occur more often with rapid-acting (mealtime) insulins than with longer-acting (background) insulins, and in general, it’s easier to adapt to changes in mealtime insulin. A change to a different long-acting insulin may take more time and effort. “It’s different for each person,” says Freeby.
During that period of adjustment, your doctor may advise you to track your blood glucose levels more closely. “Your primary concern is, of course, blood glucose control, both high and, particularly in the short term, low blood glucose,” says Gabbay.
If you struggle to adapt, your doctor can appeal your insurance company’s decision. But it’s not a quick process, there’s no guarantee that it will be successful, and each insurance company handles appeals differently.
One key, says Plourde, is paperwork to substantiate your claim that the new medication isn’t a good fit. “If you can provide documentation that the original drug worked, usually insurance companies will be OK with it,” she says. “But you need a lot of documentation proving that you need it. If you get switched, write down your blood glucose readings, write down how the new medication makes you feel, write down all the changes you notice.”
And confirm that your physician does the same, documenting in your chart what’s making you better or worse, how much you take and for how long, what else you’ve tried unsuccessfully, and why this particular medication works best for you, says Maurer.
Often the process includes more trips to the doctor, more exams, more phone calls and e-mails back and forth with your doctor. “But it’s worth it if you get the coverage you need,” says Maurer. “When you get switched, don’t give up hope that [your health care team] can find a way to get you back on that medication or find a new one that works.”
If you’re having trouble affording your insulin, the American Diabetes Association (ADA) can help. Find resources at insulinhelp.org. And learn about the ADA’s insulin affordability campaign at makeinsulinaffordable.org.