Apidra and Medicare

Yesterday, a reader emailed me and said that her Medicare Advantage Plan was no longer covering Apidra.  When she went to the Medicare website, no plans were coming up that covered it.

I went to the Medicare site and typed in Apidra to see if any plans covered it.  Apidra was no longer in their system.  I saw this:

Medicare and Apidra

I Googled Avodart – that has something to do with the prostrate gland.  Not quite the same drug category as Apidra!

Thinking maybe someone misspelled it (although unlikely because it was there last year, but you never know), I looked at the drugs in the A list and didn’t see any misspellings.  I looked for insulin glulisine and it didn’t come up that way either.  Lantus, Levemir, Humalog and Novolog were all there.  Only Apidra was missing.  Oh joy!

There was a help prompt, “why can’t I find my drug,” so I clicked that.

Medicare drug not found

Last year when they put Apidra in a higher tier, I did call my plan.  I was told that Medicare is the one that develops the formulary and sets the pricing tiers for the various drugs.

I checked my plan and they don’t have the 2013 formulary up yet.  I am sure that will be coming in the mail soon – I guess I won’t have to have a heart attack the day that comes because I already had mine yesterday. Right now the only thing I can say to do is

APPEAL

I have used other insulins and they do not work the same as Apidra does for me.  I have been able to manage my gastroparesis because it is out of my system in two hours.  Humalog and Novolog are both hanging around four hours later.  These stupid morons that set formularies and make these decisions are clueless how things work.

EDITED TO ADD:  I found out from Sanofi-Aventis that Medicare made a mistake and did not put Apidra on the search tool.  It is still covered by most Medicare plans.  See that update here.

Comments

  1. Hi Kelly,

    I’m the reader who emailed you.

    I have only been on a fast-acting, before-meal insulin (Apidra) since June of this year.

    Under my plan, I have to actually try Humalog and Novolog, before I can file an appeal. So, I’ll be doing that and expecting to have a LOT of low-blood-sugar episodes. Sigh.

    I know that you already tried Humalog and Novolog. So, it seems like you have a really good case for your plan allowing you to have Apidra.

    I can’t find any information as to why this decision was made by Medicare.

    Maybe someone can give us more details / information.

    • Thanks Beth! I am sorry that you had to be the first one to find out. How long do you have to try Humalog & Novolog before they would agree to cover Apidra?

      Although I do have a good case with the gastroparesis, there is no guarantee they will see it that way. I plan to fight to the bitter end though.

      I could not find any reason why it was not on the list at all. When I searched for Apidra on the CMS site, only 2 things up and neither had anything to do with formulary.

      • I really don’t know how long I will have to try Humalog & Novolog, before my new Medicare Advantage Plan would agree to cover Apidra (if they actually would agree).

        Because my husband recently lost his former employer’s medical insurance, I had to start on a new Medicare Advantage Plan on October 1, 2012. I need to call their customer service number, to see if I can get more information about filing an appeal re Apidra (in 2013). I think that they are covering Apidra through the end of 2012.

        As you know, they might decide that Humalog and/or Novolog are just fine for me to use. I’m dreading possibly having numerous low-blood-sugar episodes.

        Since you have gastroparesis, it does seem like you have a strong case for being allowed to use Apidra. . .

      • I hope that they don’t make you use it too long. Any changes shouldn’t take effect until the beginning of the year but sometimes they do change things other times of the year.

        I am terrified of the lows also. I dont’ think these people understand that. I am also going to ask Sanofi if they have recommendations for appeals. The timing length is a good reason for me but I know not everyone that uses Apidra has gastroparesis.

  2. Neither my current insurance nor my previous insurance covers Apidra. I tried it several times and my results with it were not spectacular enough to make it worth the battle.

    The trend in most formulary listings is and has been for many years to reduce the number of covered drugs and exclude more expensive drugs. I think that Apidra is still the new kid on the block and most decision-makers don’t understand that it is different from Humalog and Novolog.

    Sorry it looks as though you’re going to have another battle on your hands. Have you ever wondered what you would do with all of your free time if you weren’t constantly struggling with doctors and insurance companies?

    • I remembered you trying it and not having great success with it Laddie, but I did not remember that your insurance didn’t cover it.

      It does seem like they are reducing things. I guess it shouldn’t have surprised me because I have seen a couple people complain about having to switch insulin. I would be OK with paying a higher copay to get it but they apparently aren’t even allowing that since it isn’t on the list.

      I would probably be able to get the things done that I want to get done – like making a river for my village!

  3. Ugh!

    I really hope my insurance doesn’t follow suit. I was having late lows (4 hours after a bolus) with Humalog so I switched to Apidra 5+ years ago. At first all insulins were the same tier on my insurance. Then they moved Apidra to 3rd tier and I got a nice note from the insurance company saying I should try Humalog or Novolog because they were essentially the same. NOT!

    I paid 3rd tier prices for about a year before starting to use the discount card this year to get it for free. I don’t know what I will do if they stop covering it at all.

    • We probably switched around the same time Sara because I started using it in 2007. My plan also moved Apidra to the 3rd tier last year. Even at the higher prices, that at least gives us the option of using it. I really don’t know what I am going to do right now either other than keep praying that I can win an appeal. I hope your insurance company doesn’t follow suit either! They really don’t get that insulins are not the same.

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