BC/BS Coverage Options

[Arlene S.]

Liz,

I'll begin with the news I got yesterday. My husband's company has changed from our Empire BC/BS Prism plan to an Oxford plan. This means that I will have to start from scratch re: sensors coverage. Unlike Empire where MM handled the whole thing, Oxford requires a Letter of Necessity from my doctor. I'm hoping that the fact that I've been on the system for 2-1/2 years with very good results will help, but I might be in for a battle. I'm ordering a box of sensors next week from Empire.

I checked the Oxford formulary and they cover Novolog under Tier One ($15 copay) but Humalog is Tier Three with a $75 copay. I have been stocking up on Novolog because I thought we'd be using Empire. My doctor gave me a bunch of free samples.

Then today I received the formulary from Empire and I was surprised to see that both Novolog and Humalog are listed but both are now Tier Two with a $35 copay. That's not the formulary I found online. Which one do you have?

[Liz]

Liz,

I'll begin with the news I got yesterday. My husband's company has changed from our Empire BC/BS Prism plan to an Oxford plan. This means that I will have to start from scratch re: sensors coverage. Unlike Empire where MM handled the whole thing, Oxford requires a Letter of Necessity from my doctor. I'm hoping that the fact that I've been on the system for 2-1/2 years with very good results will help, but I might be in for a battle. I'm ordering a box of sensors next week from Empire.

I checked the Oxford formulary and they cover Novolog under Tier One ($15 copay) but Humalog is Tier Three with a $75 copay. I have been stocking up on Novolog because I thought we'd be using Empire. My doctor gave me a bunch of free samples.

Then today I received the formulary from Empire and I was surprised to see that both Novolog and Humalog are listed but both are now Tier Two with a $35 copay. That's not the formulary I found online. Which one do you have?

Arlene,

I really hope the transition to your new coverage goes well. Empire really has been great as far as covering diabetes related things. I had Oxford before Empire but it didn't have a prescription plan. People told me that they were still required to cover certain diabetes related supplies but I could never get an answer from them about how to do it. I didn't know anything about it at the time but I guess I needed to get strips covered as DME. Oxford kept telling me to get a prescription and send it to their mail order pharmacy, which then rejected it because I didn't have prescription coverage.

I just got the new card & pharmacy info from Empire tonight. Not only did they move Humalog & Novolog to the brand name/Tier 2 co-pay but they even put OTC human insulins in the same category. I'm pretty sure you can still get a bottle of NPH or Regular for less than $35. AND, they've moved test strips to the same tier. The only good thing I saw is that Levoxyl is back to being listed in Tier 1. When I checked online it was in bold and was shown to be the brand name co-pay.

When I had problems with the way my insulin prescription was written a few years ago my CDE ended up writing it for 3 vials/month so I haven't been getting it refilled every 3 months. I was going to ask her to write for 2 vials/month but now I won't bother since the co-pay has more than tripled. Might as well get the extra vial and refill it 3 times a year instead of 4.

[Arlene S.]

Arlene,

I really hope the transition to your new coverage goes well. Empire really has been great as far as covering diabetes related things. I had Oxford before Empire but it didn't have a prescription plan. People told me that they were still required to cover certain diabetes related supplies but I could never get an answer from them about how to do it. I didn't know anything about it at the time but I guess I needed to get strips covered as DME. Oxford kept telling me to get a prescription and send it to their mail order pharmacy, which then rejected it because I didn't have prescription coverage.

I just got the new card & pharmacy info from Empire tonight. Not only did they move Humalog & Novolog to the brand name/Tier 2 co-pay but they even put OTC human insulins in the same category. I'm pretty sure you can still get a bottle of NPH or Regular for less than $35. AND, they've moved test strips to the same tier. The only good thing I saw is that Levoxyl is back to being listed in Tier 1. When I checked online it was in bold and was shown to be the brand name co-pay.

When I had problems with the way my insulin prescription was written a few years ago my CDE ended up writing it for 3 vials/month so I haven't been getting it refilled every 3 months. I was going to ask her to write for 2 vials/month but now I won't bother since the co-pay has more than tripled. Might as well get the extra vial and refill it 3 times a year instead of 4.

Hi Liz,

Thanks. I hope the transition is smooth but I doubt that it will be without problems. I can't do anything yet because the contract will be signed tomorrow and I won't have a card or an account number until next week.

We had an Oxford plan years ago and there were no problems with getting strips as DME but they wouldn't cover pumps (my first pump was about to go out of warranty) or pump supplies. I appealed using the NY State mandate to back up my appeal. I even wrote to the state insurance commissioner. Somehow I won my appeal in spite of the insurance commissioner and my claim got paid. Months after I received a check for $800 from Oxford, I received a letter from the commissioner telling me Oxford didn't have to pay. It was such a hassle. It was a different plan and they were an independent company at the time; now they are owned by United Healtcare. Still I was shocked and upset by the change.

My ENT and my husband's allergist are the only doctors we use who are not on the new plan. The prescription drug plan is similar to that of Empire. Novolog and Novolin vials are the only Tier One insulins ($15 copay). Novo pens and cartridges are Tier Two. Even Humulin ($54 at drugstore.com) is on Tier Three with a 75 dollar copay. (The only advantage to that would be if one would get several vials at a time.) Apidra isn't even on the list. I'm going to stick with my three vials of Novolog at a time but what with stockpiling I won't need any for a while. Synthroid is Tier Two but I think it costs less than $35. It's the sensors that worry me. I should have stockpiled them. Instead I ordered them every two months.

I've been very happy with Empire but apparently the firm switched because Empire's rates went up 23%. Until this year the employees of the company my husband works for had a choice. This plan is also an EPO. This time there was no choice. The customer service at Empire was great. I just ordered my last prescription from Caremark. Oxford uses Medco. I hope they are as efficient as Caremark. And I hope they accept electronic submissions.

[Liz]

The Oxford plan my company still has is a PPO, I think. All I know is that brokers and everyone else say it's the "best" plan. No prescription coverage, referrals required to see a specialist, you can go out of network but there's a deductible/co-insurance. We switched our Empire plan from the HMO to EPO this year because the HMO premium was increasing by 30-something percent. We actually lowered the monthly premium by going with the EPO but I'm sure that will increase a lot next year. Some people stayed with Oxford because their doctor(s) weren't part of Empire's roster. Some stayed because they didn't want to change what they were used to. Those people obviously don't take maintenance meds!

I have to e-mail my CDE about getting the endo to fax Edgepark the information they need. They said they faxed her twice but got no reply.

[Arlene S.]

The Oxford plan my company still has is a PPO, I think. All I know is that brokers and everyone else say it's the "best" plan. No prescription coverage, referrals required to see a specialist, you can go out of network but there's a deductible/co-insurance. We switched our Empire plan from the HMO to EPO this year because the HMO premium was increasing by 30-something percent. We actually lowered the monthly premium by going with the EPO but I'm sure that will increase a lot next year. Some people stayed with Oxford because their doctor(s) weren't part of Empire's roster. Some stayed because they didn't want to change what they were used to. Those people obviously don't take maintenance meds!

I have to e-mail my CDE about getting the endo to fax Edgepark the information they need. They said they faxed her twice but got no reply.

I can't imagine a plan without prescription coverage. The Oxford plan I looked at last year allowed one to go out of network but it also had a good prescription drug plan. And the premiums were very high. I went to New York Magazine's Best Doctors issue and I found a NYC ENT who has an office in Chappaqua which is pretty close to us. I also found an allergist who got very good reviews. But I find the change stressful.

Is it snowing in the city? We have a couple inches already but not a plow in site in our condo complex.

[Liz]

The Oxford plan was always more expensive (premium) than Empire, which is the reason why we added a second option in the first place. Actually, I don't think our Oxford plan is the PPO anymore. I vaguely remember that last year the premium increased a lot and we opted to change the plan a bit, but I don't remember what it is now. Still no prescription coverage. It did decrease the premium and it's now less than Empire but it usually catches up at renewal time. Our Oxford renews in April and Empire in August.

I went out to do some shopping after lunch and it was snowing but by the time I got back to work it had turned to wet sleet. The last time I looked outside it was back to snowing. I have a feeling my bus ride home tonight isn't going to be much fun, but I did get to work quickly this morning.

[gigem99]

Oxford uses Medco. I hope they are as efficient as Caremark. And I hope they accept electronic submissions.

My insurance uses Medco for the rx's. They can be kind of a pain. The electronic submission is (usually) quite simple, though. Just be careful how your scripts are written. My endo had written my test strip rx that I test 6 times a day. They did the arithmetic for 3 month supply and came up with 540 strips (6 * 90). So, since they won't send partial boxes, they just sent me 5 boxes instead of the 6 I was expecting. I took literally hours of hollering at them on the phone to get them to send the extra box. When that year's script was up, they did the same thing with the new script! It didn't take as long to get it straightened out, but they can be arrogant.

I was real glad when I got a call from MM and they said they can take my scripts for onetouch strips. I've always used Medco for my infusion sets, but I'm calling MM next week to see if they can deal directly with my insurance company for my sets. I want to get different sets, and I don't want to have to argue with Medco.
Tom

[Arlene S.]

The Oxford plan was always more expensive (premium) than Empire, which is the reason why we added a second option in the first place. Actually, I don't think our Oxford plan is the PPO anymore. I vaguely remember that last year the premium increased a lot and we opted to change the plan a bit, but I don't remember what it is now. Still no prescription coverage. It did decrease the premium and it's now less than Empire but it usually catches up at renewal time. Our Oxford renews in April and Empire in August.

I went out to do some shopping after lunch and it was snowing but by the time I got back to work it had turned to wet sleet. The last time I looked outside it was back to snowing. I have a feeling my bus ride home tonight isn't going to be much fun, but I did get to work quickly this morning.

Our renewals are in January and as soon as I get the ID and Group numbers I'm going to call MM (I spoke to a really nice and helpful guy there) to get the information on record so they can send me strips and pump supplies. Then I will call Oxford to find out exactly how to initiate the procedure for sensors.

Our snow plows (our development has a service) never showed up today. Even main roads were not plowed. It took my husband two hours to get home from work. It's a 7-1/2 mile trip. Last year (February) I fell on ice and broke my ankle in three places and I was in a wheelchair for two months. There were so many times when I was one of about three people who showed up at work even in the worst snowfalls, and now I'm terrified of even going outdoors when there is even a possibility of ice. But right now I am looking at all the snow and wishing I could go out and build a snowperson. Oh, well. Hope you made it home okay. It's hard to beleive it was 66 degrees out there on Monday.

[Arlene S.]

My insurance uses Medco for the rx's. They can be kind of a pain. The electronic submission is (usually) quite simple, though. Just be careful how your scripts are written. My endo had written my test strip rx that I test 6 times a day. They did the arithmetic for 3 month supply and came up with 540 strips (6 * 90). So, since they won't send partial boxes, they just sent me 5 boxes instead of the 6 I was expecting. I took literally hours of hollering at them on the phone to get them to send the extra box. When that year's script was up, they did the same thing with the new script! It didn't take as long to get it straightened out, but they can be arrogant.

I was real glad when I got a call from MM and they said they can take my scripts for onetouch strips. I've always used Medco for my infusion sets, but I'm calling MM next week to see if they can deal directly with my insurance company for my sets. I want to get different sets, and I don't want to have to argue with Medco.
Tom

Thanks for the heads up, Tom. I plan to get my strips, pump supplies (and hopefully sensors--if they approve them) through MM. According to the rep I spoke to Oxford will let me do that. I plan to use Medco for my maintenance meds, some of which are generics and I will make sure my PCP puts DAW on my Synthroid. Some meds I'll continue to get from my local pharmacy.

I'm assuming that Medco is a pharmacy. Do you get your strips as a pharmacy item or as DME. Does Medco also handle DME? I can't get any information on their website because I don't have our ID numbers yet.

[gigem99]

I'm assuming that Medco is a pharmacy. Do you get your strips as a pharmacy item or as DME. Does Medco also handle DME? I can't get any information on their website because I don't have our ID numbers yet.

My OneTouch strips are covered as a tier 1 pharmacy. I've never seen anything about DME's on their site. One type of Sils is covered as a tier 2 (19 mm), but the 13 mm is a "brand name" and not showing covered at all. It all gets pretty confusing, and I just don't want to deal with them anymore. I hope I can go straight through MM.
Tom

[Linda B]

I was real glad when I got a call from MM and they said they can take my scripts for onetouch strips. I've always used Medco for my infusion sets, but I'm calling MM next week to see if they can deal directly with my insurance company for my sets. I want to get different sets, and I don't want to have to argue with Medco.

I have always gotten my sets from MM. If they are handling your strips, I can't imagine why they couldn't handle your sets.
Linda

[Arlene S.]

My OneTouch strips are covered as a tier 1 pharmacy. I've never seen anything about DME's on their site. One type of Sils is covered as a tier 2 (19 mm), but the 13 mm is a "brand name" and not showing covered at all. It all gets pretty confusing, and I just don't want to deal with them anymore. I hope I can go straight through MM.
Tom

Check with your insurance company. Strips and pump supplies should be covered under DME as well as pharmacy. I noticed that the formularies of my present and future pharmacies list strips. Only One-Touch is Tier 1 with Oxford. But I always get them as DME with no copay and any quantity my endo wants to prescribe. I use Edgepark now but I plan to switch everything over to MM.

[mjshaw]

Folks,

I read with interest your posts. I also have Empire BCBS. I am new on the pump, so I am very curious to read what people have to say. I also have MEDCO. Yes, they can be a pain. Not real organized in my opinion, but not to bad. There is also a place online called Focus Pharmacy. It is focuspharmacy.com (I am not affiliated with them). You fill out a simple form on their website. They will verify your insurance and you are ready to go. They do infusion sets, and prescriptions. The best thing about them is that they take the amount the insurance gives them, leaving you with no copay. They even do the paperwork for you. I got a call back the next day. Very nice people. I can get all my pump supplies (including strips), and prescriptions through them. No out of pocket. Just wanted to pass this along. Have them check your coverage. If you qualify, they will send info to your doctor. They will then ship out the prescriptions (usually overnight or two day). Shipping is free!!! I was accepted, so that is such a huge relief.

Mike

[Liz]

Folks,

I read with interest your posts. I also have Empire BCBS. I am new on the pump, so I am very curious to read what people have to say. I also have MEDCO. Yes, they can be a pain. Not real organized in my opinion, but not to bad. There is also a place online called Focus Pharmacy. It is focuspharmacy.com (I am not affiliated with them). You fill out a simple form on their website. They will verify your insurance and you are ready to go. They do infusion sets, and prescriptions. The best thing about them is that they take the amount the insurance gives them, leaving you with no copay. They even do the paperwork for you. I got a call back the next day. Very nice people. I can get all my pump supplies (including strips), and prescriptions through them. No out of pocket. Just wanted to pass this along. Have them check your coverage. If you qualify, they will send info to your doctor. They will then ship out the prescriptions (usually overnight or two day). Shipping is free!!! I was accepted, so that is such a huge relief.

Mike

I wonder if different Empire BCBS plans use different mail order pharmacies? I've never heard anything about Medco. Right now I get pump supplies from Minimed (sets, reservoirs, sensors, IV Prep wipes). Under my plan they are covered 100% so no co-pay to worry about. I get prescription drugs (like insulin) from NextRx and have no problems with them so far. Test strips I get as DME from Edgepark also with no co-pay. If I get them from NextRx I would have a $35/month co-pay (or $70 for 90 days) and as a prescription/pharmacy/drug benefit item I would be limited to 200/month. Minimed isn't able to bill strips as DME but Edgepark is an in-network provider for Empire so I get them there. Empire had actually sent out a letter a year or so ago recommending Edgepark for test strips. Again, no problems with them. They did all of the work of contacting the endo and getting the authorization.

[mjshaw]

Liz,

I think they do. Medco by mail is what they recommend. I get three months of meds for about the price of one month at local pharmacy. My test strips are covered with a copay. Had to pay 55 bucks for 400 (which isn't bad). This is why I will use Focus. 55 bucks is 55 bucks. I will be able to get all of my meds through them the next time.

I have used Edgepark in the past. They were great. Good service from start to finish. I never got anything about Edgepark, but that is probably because they go through Medco.

There are options out there. Please check them out. You might be surprised. It only takes a little time, and who knows.