How can I make sure I don’t run out of medications and supplies?

• Develop a system for remembering to refill your prescriptions and supplies BEFORE THEY RUN OUT.  There are phone apps to help you track and refill prescriptions.
• If your prescriptions are filled at a local pharmacy, call several days in advance in case the pharmacy has to order your medication or the doctor needs to call in refills.
• Before your next diabetes team appointment, make sure you have enough medications and supplies for at least three months. If you are going to run short before you are seen again, ask for prescription renewals at your appointment.
• If you get your supplies through a mail order company, set up delivery at least two weeks in advance to avoid delays and to allow extra time for delivery.
• If you travel, talk to your pharmacist in advance about having adequate medication for your trip.

What is the difference between a refill and a renewal?

• Prescriptions are usually written for a three-month supply with three refills, which gives you a full year of medication and supplies. Your pharmacy will only give you three months of medication at a time. So, when you use up your first three-month supply, you will go back to the pharmacy for a refill. Look at the label on your prescriptions and it will say how many refills you have left. After you have used up your third refill, you will need to have your prescription renewed by your provider.

Who do I call for information about my prescription plan?

• A Pharmacy Benefit Manager (PBM) helps manage your prescriptions (examples: Future Scripts, Express Scripts, CVS Caremark).
• You can find the PBM list on the back of your insurance card.
• If it is not there, call your insurance company (member services) and ask.

Some of my prescriptions are covered under my prescription plan and some are covered by my DME benefit (durable medical equipment). What does this mean and what do I need to do? 

• Some of your diabetes medications may be paid for through your prescription benefit (insulin and glucagon for example) and some of your diabetes supplies may be filled through your DME benefit (syringes, test strips and lancets, for example).
• If you have a DME benefit, you have to go through a DME company to get these items covered.
• This distinction is important because prescriptions have copays and DME supplies do not. In order to know what your costs for supplies will be, it is important to know which benefit(s) you will be using.
• Call your insurance member services to find out if you have DME benefits and how they work.

Can I go to the local pharmacy to get my diabetes medications?

• Some insurances allow you to get your medications from a local pharmacy. Others may require that you use a mail order pharmacy. Mail order companies usually send out a three-month supply and are typically less expensive.

I was getting my prescriptions filled at my local pharmacy, but now I have to use a mail order pharmacy. Why?

• Many insurance companies require you to order medications you will be taking for a long time (like insulin) through a mail order pharmacy. They call these maintenance medications.
• Some insurance companies only allow a certain number of prescriptions through your local pharmacy. This is usually for new prescriptions or prescriptions you will only be taking for a short time, like antibiotics. This is called “retail allowance.” So, if you were asked to switch to a mail order pharmacy, you’ve most likely reached your retail allowance.
• Some insurance companies only have retail allowance for “maintenance” supplies, such as test strips and lancets.

What happens if my insurance company doesn’t approve a medication I’m prescribed?

• When this is the case, they may say it is not “on the formulary.” A formulary is a list of medications your insurance company prefers.
• Whenever possible, your diabetes provider will prescribe medications that are on the formulary for your insurance company. But they cannot always be aware of every approved brand for each insurance company. When that’s the case, your doctor may have to rewrite the prescription to make sure your medication is covered.
• Be aware that generic equivalents are permissible by law unless a specific brand is required by your diabetes team. If you are prescribed a specific brand, your co-pay may be much higher. It’s always a good idea to ask your doctor if a generic brand is available and appropriate for you.
• If there is no medication on the formulary that will work for you, your provider will complete a prior authorization request. The provider will contact your insurance and explain why you need a medication that is not on the formulary.
• The prior authorization process usually takes up to 72 hours for approval.
• If the medication is not approved, an appeal process may be available.

I usually test eight times per day and my provider wrote the prescription to cover the right number of test strips. My insurance company says they will only cover four test strips per day. What should I do?

• Some insurance companies require a prior authorization if your provider prescribes a quantity of medication or supplies that is over what is usually prescribed. Contact your provider and ask them to submit a prior authorization request to your insurance.