How does a health insurance policy handle the cost of insulin and other essential medications required for diabetes management? Are there any restrictions or limitations on the type or brand of insulin covered?
—Name withheld on request
The industry has slowly begun catering to the specific needs of such customers. A few health insurance providers prioritize comprehensive coverage for individuals managing diabetes. These policies typically include coverage for insulin and essential diabetes medications within the prescription drug coverage section. There is also an emphasis on encouraging the use of cost-effective generic medications whenever possible. However, insurance providers understand that certain individuals may require specific brands or types of insulin for medical reasons. In such cases, they at times collaborate with healthcare providers to ensure coverage for medically necessary medications.
Insurance providers typically maintain a formulary, which is a list of drugs covered under their plans. Diabetes medications, including insulin, are typically part of this formulary, and they may be categorized into different tiers that impact cost-sharing requirements for policyholders. To ensure that prescribed treatments align with best practices for diabetes management, insurance policies may require prior authorization for certain medications, including specific types of insulin.
Some insurance providers may also implement step therapy protocols to promote the use of cost-effective medications initially. However, they remain committed to accommodating patients’ needs when healthcare providers deem a particular medication as essential.
Policyholders are typically responsible for a portion of their medication costs, which can take the form of co-payments or co-insurance, depending on the specific terms and conditions of the policy. Deductibles may also apply in some cases, affecting prescription coverage.
To help policyholders save on medication costs, insurance providers often maintain networks of preferred pharmacies. Using these network pharmacies can lead to cost savings.
I want to buy a diabetes specific plan but I am worried about out-of-pocket expenses. Which type of diabetes care plan should I buy that gives me the maximum coverage?
—Name withheld on request
The out-of-pocket expenses associated with diabetes are categorized under two buckets. One is medical and supplies costs that include medicines, insulin pumps, glucose monitors, and the other is expenditure on medical examination/diagnostic tests such as general/specialist consultation charges, consultation with an ophthalmologist, HBA1c, creatinine, chest X-ray, spirometry test, ECG, cholesterol profile, etc. The medicine and diagnostic costs may vary based on comorbid conditions along with diabetes. A few of the health insurance plans reimburse such out-of-pocket expenses under a Chronic Management Programme. Diabetes plans may or may not come with co-payment and/or deductibles depending on the product benefit structure of the company.
Such customers should look out for comprehensive covers, including the out-of-pocket expenses, and buy a suitable product. While only a few insurance companies offer such covers, it is really worthwhile to invest in such a cover that takes care of all the health and protection needs of such customers.
Anuradha Sriram is chief actuarial officer, Aditya Birla Health Insurance.
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Updated: 09 Nov 2023, 10:46 PM IST