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Cost and coverage of diabetes medications and CGM devices is one of the biggest challenges our collaborative members face. As part of our ongoing effort to support our practices in navigating the insurance coverage process, we hosted a series of lightning discussions with care managers, physicians, pharmacists, and other office staff who are part of MCT2D. From these discussions, we compiled a list of 10 tips that we hope will help your practice tackle many challenges related to insurance coverage.
General Coverage and Prior Auth
1. Fewer cooks in the kitchen
Tame the chaos of prior authorizations, claims appeals, and patient assistance program applications by assigning a point person at your practice(s) to lead these efforts and become the “expert.” Practices that had “fewer cooks in the kitchen” were able to reduce overall administrative time wasted across the practice and were able to support more patients with fewer setbacks.
In our March 2023 coverage survey (n=292), we asked MCT2D clinical champions: Do you have a specific person in your office who handles all prior authorizations? The chart summarizes response for all seven MCT2D regions as well as the collaborative as a whole (see right).
2. Know the criteria and have your notes or smartphrase ready.
Copy and paste is your friend. Use EMR dot phrases/SmartPhrases or go old-school with copy and paste to ensure that all required criteria are captured in the notes.
Sharing is caring. Talk to your colleagues about their dot phase or SmartPhrases and share your own.
MCT2D is building an online library of dot phrases that can be copied and saved in your practice's EMR. Do us a favor and submit your dot phrases to our crowdsourced MCT2D library. Submitting a dot phrase will grant you early access to the library!
Patient Empowerment
3. Assign patient homework.
Share our Affording Your Diabetes Care toolkit with your patients, with tips on how to talk to their insurance company to get the coverage answers they need.
Alternatively, build a dot phrase/SmartPhrase that has key questions for patients to ask their insurance company, so they have it available when they get home.
If they need a more hands-on approach, pick one GLP-1 RA as a starting point and send it to the pharmacy. Advise the patient to ask the pharmacist about the cost of the copay before they pick up the prescription, and to consider if this copay will be affordable for them long term. If the copay is too expensive for them, they can decline the medication and should reach out to their insurance plan to find out the preferred and lowest-cost drug in the class. Then notify their doctor’s office for a new prescription.
4. Get a head start. Leveraging samples (if you have access to them).
- Use medication samples to bridge the prior authorization and unknown coverage period and get patients started on the medication quicker.
- Use CGM sensor samples to demonstrate the utility of real-time data to patients, to verify the patient’s ability to use the technology, and/or to gather a sample of glycemic data for patients that are not regularly testing.
Continuous Glucose Monitors
5. Use Parachute Health
Parachute Health is a free, online platform that speeds and simplifies the electronic prescribing of durable medical equipment. May not be available for all payers or DME suppliers. The platform allows healthcare teams to electronically communicate order updates and get notified when coverage issues arise. www.parachutehealth.com
Note: If you’re part of a larger health system, coordinate Parachute Health account access with your administrators before setting up an individual account. Some healthcare organizations have established business associate agreements with the platform that regulates account access.
Watch our recent CGM Operationalization Panel Discussion, with tips on navigating DME and Medicare, including using Parachute. MCT2D primary care members can earn physician-level engagement VBR credit for 2023 by watching and completing a brief post-survey.
6. Know your CGM company reps
Reps from CGM companies like Dexcom and Abbott can help make prescribing CGMs easier. They can help clarify payor coverage criteria, recommend preferred pharmacies and/or DME suppliers, and offer samples.
Patient Assistance Programs (PAP)
7. Host PAP Parties
Have patients come into the office with their required documentation to complete the patient portion of PAP applications as a group. This saves having to go back and forth with individual patients, reduces errors in the application, and saves staff time. Hosting a PAP re-application party in October or November may be especially helpful in handling volumes of patients who need to reapply. Low carb snacks recommended!
8. When possible, use programs that deliver meds to patients’ homes rather than the office
Having meds delivered directly to the patient’s home saves hours of staff time. The following patient assistance programs can deliver meds directly to a patient’s home:
- Lilly Cares - Trulicity, Basaglar, Humalog and Humulin
- AZ & Me - Bydureon Bcise, Byetta, Farxiga
- BI Cares - Jardiance
Download our guide to Patient Assistance Programs—a complete guide to SGLT2 i and GLP-1 RA programs, with links to applications, fax numbers, and income guidelines.
9. Address the elephant in the room right away with patients: Cost, coverage, and opportunities for discounted or free medications, if they qualify.
- Introduce Patient Assistance Programs for patients on Medicare Part D or who are uninsured. Mention copay cards for patients with commercial insurance.
- More patients qualify than you think. Know the general income ranges to educate. Our PAP guide outlines income requirements for households of 1 or 2 as well as Federal Poverty Line guidelines.
10. Set clear expectations with patients and assign patient homework.
Patients are solely responsible for gathering necessary financial and tax documentation, as well as filling out their portion of the application. Set expectations that it is the patient’s responsibility to contact the manufacturer/foundation to check the status of their application and initiate renewal in October/November for the next year.
Other recommendations from our interviews
Try Advanced Diabetes Supply
They have a patient cost program that reduces copay for CGMs www.northcoastmed.com
Try Pharmacy Advantage
They work directly with patients to navigate coverage for their prescriptions. Know the preferred pharmacy for your health system or plan. HAP has a preferred agreement with Pharmacy Advantage. Recommended by Henry Ford Hospital
MCT2D would like to say a big thank you to the practices who took time out of their busy day to share these tips with us and the collaborative. Positive change happens because of your continuing efforts to navigate and break down insurance coverage barriers.
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ccteam@mct2d.org
Support for The Michigan Collaborative for Type 2 Diabetes (MCT2D) is provided by Blue Cross Blue Shield of Michigan as part of the BCBSM Value Partnerships program.
Although Blue Cross Blue Shield of Michigan and MCT2D work collaboratively, the opinions, beliefs and viewpoints expressed by the author do not necessarily reflect the opinions, beliefs and viewpoints of BCBSM or any of its employees.