Your Guide to Navigating Insurance for Type 2 Diabetes

Coverage for diabetes care

Understanding your insurance coverage is crucial not just for managing diabetes but also for maintaining overall health.

A 2020 study shows that routine checkups alone may not significantly improve physical and mental health for middle-aged adults with diabetes. This underscores the importance of ensuring that your insurance covers a wide range of services, including regular screenings and treatment for additional health conditions.

Let’s explore the different aspects of diabetes care and how insurance coverage applies to each.

Essential diabetes-related services and supplies

Routine care

Insurance and Medicare typically cover routine care for diabetes, including doctors’ visits and lab tests.

These may include the following:

• regular checkups for blood sugar monitoring
• A1C tests every 3 to 6 months to measure average blood sugar levels over the past 2 to 3 months
• regular blood pressure checks
• regular cholesterol tests
• annual kidney function tests
• annual eye exams to check for retinopathy
• regular foot exams to check for signs of nerve damage or circulation problems

It’s important to review your specific plan details to understand the extent of coverage and any out-of-pocket costs.

Medications

Most insurance plans cover diabetes medications, including insulin, though the cost to you can vary depending on your plan’s formulary, copay, and deductible.

Here is a breakdown of Medicare coverage:

• Medicare Part D: Part D covers prescription drugs, including insulin that you inhale or inject with a syringe. However, out-of-pocket costs can depend on the specific Part D plan and its formulary.
• Medicare Part B: Part B covers certain types of insulin if used with an insulin pump, as well as some diabetes supplies like blood sugar testing monitors, test strips, and lancets.
• Medicare Advantage Plans (Part C): Part C plans often provide additional coverage beyond what Original Medicare offers, including prescription drug coverage.

Diabetes supplies

Insurance providers, including Medicare, typically cover the following diabetes supplies:

• Blood glucose meters: devices used to measure blood sugar levels
• Test strips: used with glucose meters to test blood sugar levels
• Lancets and lancing devices: small needles and devices used to prick the skin to obtain a blood sample for testing
• Insulin pumps: devices that deliver insulin continuously throughout the day
• Continuous glucose monitors (CGMs): devices that track blood sugar levels in real time
• Syringes, pens, and needles: used for injecting insulin

Medicare plans can vary in covering diabetes supplies. Here’s a general breakdown:

• Medicare Part B: Part B covers certain diabetes supplies, including blood glucose meters, test strips, lancets, and insulin pumps (for those who meet specific criteria).
• Medicare Part D: Part D covers some supplies, like syringes, needles, and alcohol swabs. However, coverage can vary depending on the specific Part D plan and its formulary (the list of covered drugs).
• Medicare Advantage Plans (Part C): Coverage for diabetes supplies under Part C can vary depending on the specific plan.

Access to specialists

Both private insurance and Medicare Part B may cover the following diabetes specialists:

• Endocrinologists manage and treat diabetes and related hormone conditions.
• Diabetes educators provide education and support for diabetes management.
• Registered dietitians (RDs) assist with dietary planning to manage diabetes.
• Certified diabetes care and education specialists offer specialized training and support for diabetes care.
• Podiatrists address foot care to prevent diabetes-related complications.

Medicare Advantage Plans (Part C) may also cover these specialists, often with additional benefits. Always check specific plan details for coverage information.

Preventive services

Preventive services for diabetes covered under private insurance and Medicare Part B include the following:

• Annual wellness visits: typically covered, including screenings and management planning
• Diabetes self-management training: often covered if prescribed by a doctor
• Medical nutrition therapy: usually covered when deemed medically necessary
• Foot exams: often covered, particularly for people with diabetes-related complications
• Blood pressure checks: typically covered as part of routine care

Choosing a healthcare plan

When choosing an insurance plan, assess your medical needs, expected out-of-pocket costs, and coverage for essential diabetes management services.

Here’s a breakdown of various plans:

• High tier plans: These plans offer extensive coverage with lower out-of-pocket costs and good access to specialists and preventive services. They’re ideal for managing diabetes because they cover medications and specialist visits with minimal extra costs.
• Standard plans: These plans provide essential coverage with moderate premiums but come with higher deductibles and copays. They work for diabetes management but may result in higher costs for medications and specialist care.
• High deductible health plans: These plans have lower premiums but higher deductibles. They can be paired with health savings accounts (HSAs) to save money for medical expenses, but you need to pay more out of pocket before coverage starts.
• Catastrophic plans: These plans have low premiums and high deductibles, covering essential benefits only after the deductible is met. They are less suitable for managing diabetes due to high out-of-pocket costs.

Medicare coverage for diabetes care

Medicare plans support diabetes care by covering various aspects of treatment.

Here’s a brief summary of how these work:

• Medicare Part A (hospital insurance): Medicare Part A primarily covers inpatient hospital stays and emergency treatments but doesn’t cover routine diabetes care.
• Medicare Part B (medical insurance): Medicare Part B covers outpatient care, including doctors’ visits and some home health services. It provides coverage for diabetes management, essential supplies like glucose meters, test strips, and lancets, and up to 12 hours of diabetes self-management training per year.
• Medicare Part D (prescription drug coverage): Medicare Part D provides coverage for prescription medications, including insulin and other diabetes drugs.

Navigating prescription coverage

Navigating prescription coverage for diabetes can be complex. It often involves understanding insurance formularies, dealing with different coverage tiers, managing out-of-pocket costs, and handling appeals for noncovered medications.

Drug formularies

A formulary is a list of prescription drugs covered by your health insurance plan. It categorizes drugs into tiers, with different costs for each tier. Typically, generic drugs are in lower cost tiers, while brand-name drugs may be in higher cost tiers.

Check your plan’s formulary when starting a new medication, switching medications, or reviewing annual coverage options. The formulary is typically available on your insurance provider’s website or in your plan’s benefits booklet.

Tips for saving money

• Use generic drugs: Opt for generic versions of medications, which are usually cheaper than brand-name drugs.
• Use discount cards: Consider using online tools or prescription savings cards from drugstores (e.g., Walgreens Prescription Savings Card) to find lower prices on medications.
• Compare prices: Check prices at different pharmacies, including online or mail-order options, to find the best deal.
• Use discount programs: Look for manufacturer discounts, coupons, or patient assistance programs that can reduce medication costs.
• Choose 90-day supplies: If your medication is stable, consider a 90-day supply, which can be more cost effective than a 30-day supply.

What to do if a medication isn’t covered

• Ask your doctor for alternatives: Your healthcare professional may suggest a different medication that is covered by your plan.
• Request an exception: Contact your insurance company to request a formulary exception. If necessary, provide medical documentation to support why the drug is needed.
• Appeal the decision: If your exception request is denied, you can appeal the decision. Follow your insurance company’s appeal process and provide any additional information requested.
• Consider other insurance options: If necessary, review and compare other insurance plans during open enrollment to find one that better meets your prescription needs.

Managing costs and maximizing benefits

Strategies to reduce out-of-pocket costs

• Explore patient assistance programs and copay cards: Use patient assistance programs and copay cards from pharmaceutical companies or discount services to lower prescription costs.
• Use generic medications: Opt for generic versions of prescription drugs, which are typically less expensive than brand-name medications. Generics contain the same active ingredients and are just as effective but cost significantly less.

A 2021 study compared the cost and effectiveness of generic and branded drugs for type 2 diabetes. Researchers found that generic drugs offer significant cost savings compared with branded ones.

Among single-drug treatments, glimepiride had the highest cost variation, while vildagliptin had the lowest. Despite these cost differences, both branded and generic drugs worked similarly in controlling blood sugar levels.

Researchers suggest that generic drugs can cut treatment costs without reducing effectiveness, and healthcare professionals should promote their use.

Health savings accounts (HSAs) and flexible spending accounts (FSAs)

Health savings accounts (HSAs) and flexible spending accounts (FSAs) are both useful tools for managing diabetes-related expenses.

Health savings accounts (HSAs)

HSAs are savings accounts that let you set aside pretax money to pay for healthcare costs, including diabetes-related expenses like doctors’ visits, medications, and supplies, like glucose meters and test strips.

If you have a high deductible health plan, you’re eligible to contribute to an HSA.

In 2024, you can contribute up to $4,150 for an individual or $8,300 for a family. The money in an HSA rolls over each year, so you don’t lose it if you don’t spend it right away.

Flexible spending accounts (FSAs)

FSAs also allow you to set aside pretax dollars for medical expenses, including diabetes care such as copays, medications, and supplies.

Unlike HSAs, FSAs usually require you to spend the money within the plan year or you’ll lose it.

For 2024, the contribution limit for FSAs is $3,200 per year. FSAs can help cover a wide range of diabetes-related expenses, making it easier to manage your healthcare costs throughout the year.

Both HSAs and FSAs are valuable tools for managing diabetes expenses, offering tax advantages and helping you plan for healthcare costs.

Resources and support

Where to get help

• Insurance customer service: Reach out to your insurance provider’s customer service for assistance with understanding your coverage, resolving billing issues, and getting answers to any questions about your policy.
• Case management: Some insurance plans offer case management services, in which a dedicated case manager can help coordinate your care and connect you with additional resources.
• Advocacy groups: Organizations like the American Diabetes Association offer support, resources, and advocacy for people managing diabetes.

Educational resources

• American Diabetes Association (ADA): The ADA website offers a wide range of resources, including information on managing diabetes, navigating insurance, and staying informed about the latest research.
• Centers for Disease Control and Prevention (CDC): The CDC’s Diabetes section offers reliable information on diabetes prevention, management, and statistics. It also provides resources for understanding the effects of diabetes and accessing support programs.
• MySugr: MySugr is a popular diabetes management app that helps users track blood sugar levels, meals, and insulin use. It’s available on iOS and Android devices.
• Glooko: Glooko is another diabetes management app that allows users to monitor glucose levels, medications, and physical activity. It’s available on iOS and Android devices.

Takeaway

Managing diabetes often requires complex care due to the need for regular monitoring, medication, lifestyle adjustments, and coordination with various healthcare professionals and providers.

By staying informed and proactive, you can effectively manage your diabetes care and make the most of your insurance benefits.