For about a week, Daniel and Elizabeth Salls heard “no” repeatedly when they tried to get their health insurance to cover a new state-of-the-art insulin pump for their 14-year-old daughter, Cate, who was diagnosed with Type 1 diabetes 10 years ago.
The insulin pump they wanted was highly anticipated. It would free Cate of some of the painstaking management required to maintain the right level of insulin. It had been in development for years.
Daniel Salls called it the “closest thing we’ve seen to an artificial pancreas,” because it receives continuous data from another device and automatically releases insulin into the body as needed from a semi-permanent pod that attaches to an arm or other body part.
“It’s something we’ve really been looking forward to,” he said.
Last month, the Sallses got the e-mail from the pump’s maker that they’d been waiting for: “We are excited to let you know” the new pump (called an Omnipod 5) “can now be prescribed by your doctor. We are thrilled this day has arrived.”
Soon, Cate’s endocrinologist at Baystate Medical Center in Springfield wrote the prescription. (The Salls family lives in the Western Massachusetts town of Sunderland.)
Then, the problems began.
On May 23, the Sallses received a voicemail from the endocrinologist’s office: “It looks like when we did the actual insurance eligibility check they are telling us the Omnipod 5 is still a plan exclusion.”
Daniel Salls said he immediately called his family’s health insurer, Point32Health (which is the name of the company after the merger of Harvard Pilgrim Health Care and Tufts Health Plan), to challenge the exclusion.
But Daniel said the conversation ended without him feeling satisfied that he knew why the pump wasn’t being covered. That’s when he wrote to me, leading me to ask Point32Health about the “plan exclusion,” which is a provision in an insurance policy that eliminates coverage for certain things.
Point32Health replied to me without mentioning “plan exclusion.” Instead, it said the pump in question “is not currently available for prescription as it is in limited market release and not available to the general public.”
Once the Omnipod 5 system is made available for prescription, Point32Health will “fully assess” it “for policy and coverage decisions,” the e-mail said. That sounded to me like a recipe for more delay.
Later that day, the Sallses got an unexpected call from their insurer giving them a “prior authorization” number, along with instructions to give it to their endocrinologist.
A prior authorization, in health insurance jargon, usually means approval of coverage, the opposite of “plan exclusion.”
“Fingers are crossed, we’ll see where another three hours on the phone leads tomorrow,” Daniel told me in a text message, with only slight exaggeration. He also said he thought my involvement may have played a role: “There was a definitive change in the tone and tenor of our interactions with them as the day progressed.”
The next communication I received from Point32Health, in reply to more questions, said: “We are reviewing requests for this product and approving when medically necessary. We now have to wait for it to become available.”
That seemed like progress, compared with the earlier, bureaucratic-sounding statement about needing to “fully assess” the pump “for policy and coverage decisions.”
So I contacted Insulet, the Acton-based company that makes the Omnipod 5, and asked if the pump was available.
An Insulet spokesperson replied: “With a limited distribution network, any physician can write a prescription and any patient that has access and insurance coverage can get our product. They just have to go through a pharmacy that maybe they’re not currently going through.”
On the same day I got that explanation, Daniel called Optum Rx, a prescription drug benefit provider, which is an approved supplier under the Sallses’ health care plan. Optum Rx said it had the Omnipod 5 and that it could ship it to them once approved by Point32Health, Daniel said.
When I asked Point32Health for an explanation about the original denial, it said: “There were several contributing factors to this. Because the product is new and according to the manufacturer not widely available yet, it was coded in the system in the same way as the Omnipod DASH product (older generation device), which was free from the manufacturer. We generally exclude coverage for products that are offered at no cost by a manufacturer.”
Bottom line? “We’ve asked Optum Rx to ship the product to the member as soon as possible,” Point32Health said.
Last Wednesday, it arrived at the Sallses’ house.
Daniel and Elizabeth Salls say they spend countless hours on the phone managing the flow of prescriptions and medical devices Cate needs. It’s a world packed with trap doors and blind alleys.
I’m sure no harm is intended, but sometimes wrong information does get out about what’s covered and what’s not. Savvy consumers know to press on.
Consumers are usually at a huge disadvantage when dealing not only with insurers but also medical providers and suppliers. Sometimes, what they say is confusing and contradictory. Sorting through it all can be exhausting and dispiriting.
At this point, the Sallses know how to persist. But of course not everyone has the time and ability to do what the Sallses say they routinely do.
A better, more simplified system is needed.