What You Should Know About COVID-19 Vaccines and Diabetes

This content originally appeared on diaTribe. Republished with permission.

By Eliza Skoler and Dr. Francine Kaufman

Last updated: March 22, 2021

COVID-19 vaccines have been authorized for use in the United States and in many parts of the world. We’re here to answer questions for people with diabetes. Are the vaccines safe? How do the vaccines work and does it matter which one I get? What are the side effects, and how will the vaccine affect my blood sugar? What can I do after I am vaccinated?

Now that three COVID-19 vaccines have been authorized for use in the United States, and ten more around the world, many questions are circulating about the vaccines, their safety, and when to get vaccinated. While timing may differ by state and even between sites, people with type 2 diabetes or obesity will be eligible for early vaccination in the US in the coming months, though this may not be the case for millions of others – including those with type 1 diabetes and loved ones who are not currently recommended by CDC to receive the vaccine early. As states begin to distribute the vaccines, we’re here to answer your questions about COVID vaccination in the US; we’ll update this article as more information becomes available.

Click to jump down to a group of questions:

Why get the vaccine?
Why should I get the COVID vaccine?
How does the COVID-19 vaccine work?
How do mRNA vaccines work?​
How do viral vector vaccines work?

Vaccine Safety
Is the vaccine safe for people with diabetes?
Does it matter which vaccine you get?
Which vaccine is best for people with diabetes?​
What are the side effects? Can the vaccine be dangerous?
How will the vaccine affect my blood sugar levels?
Do diabetes medications affect the vaccine?
Should I get vaccinated if I have diabetes and other health conditions?
What is the AstraZeneca vaccine?

Getting the Vaccine
When will people with diabetes get the vaccine?
How will I know when it’s my turn to get the vaccine?
How much does the vaccine cost?
What should I expect at my vaccine appointment?
I had COVID-19 – should I still get vaccinated?
If I have symptoms of COVID-19 now should I get the vaccine?

After Receiving the Vaccine
What happens after I get the vaccine – can I still infect people with COVID?
Can I see people now that I am vaccinated?
Is one dose of the COVID vaccine effective?
Does the vaccine protect against the new variant of COVID?
Can I get COVID from the vaccine?
Are other vaccines coming?
When can I stop wearing a mask?

Why get the vaccine?

Why should I get the COVID vaccine?

The vaccine has the ability to protect you, your loved ones, and your community. It will help your body’s immune system fight off a COVID-19 infection – this means that if you are exposed to COVID, your body can protect you and significantly reduce your chances of getting sick or experiencing severe complications from the virus. Two of the vaccines that are currently authorized in the US (from Pfizer-BioNTech and Moderna) are almost 95% effective at preventing symptoms of COVID in adults who have been exposed, and the third vaccine (Johnson & Johnson) is 85% effective at preventing severe COVID infection. In other words, if you are vaccinated with any of the three and then come into contact with someone who has COVID, you probably won’t get sick.

To stop the global spread of COVID-19, the majority of people around the world will have to become immune to the virus. The COVID vaccine – like the many vaccines that protect us from small pox, measles, the flu, and other illnesses – will play a major role in improving the health and wellbeing of people across the globe.

How does the COVID-19 vaccine work?

There are currently three vaccines that have received emergency use authorization in the US: the Pfizer-BioNTechModerna, and Johnson & Johnson vaccines. The Pfizer-BioNTech and Moderna vaccines are similar – both use messenger RNA (mRNA) to target the “spike proteins” on COVID-19 virus molecules. The Johnson & Johnson vaccine is a viral vector vaccine that also targets the spike proteins.

How do COVID mRNA vaccines work?

mRNA contains genetic instructions (like a blueprint) for making specific proteins in cells. The mRNA in COVID vaccines was developed by scientists to trigger human cells to make harmless COVID spike proteins, and after the proteins are built the vaccine mRNA is destroyed. The body’s immune system then recognizes these foreign proteins and builds antibodies against them. This means that if you are later infected with COVID-19, you’ll have antibodies that recognize the spikes on the viral molecule and can destroy it. To learn more about this process view this detailed, interactive piece from the New York Times.

mRNA vaccines are not “live” vaccines – the live virus is not injected into a person’s body. This means that you cannot get COVID from the vaccine. Similarly, the vaccine will not alter your own genes.

How do COVID viral vector vaccines work?

Similar to an mRNA vaccine, a viral vector vaccine causes the body’s cells to make harmless COVID-19 spike proteins so that it can learn to recognize the foreign proteins and build antibodies against them. Later, if you are infected with COVID-19, your body will have antibodies ready to fight off the virus.

Instead of using mRNA, a viral vector vaccine contains the DNA for a different, harmless virus. In the case of the Johnson & Johnson vaccine, it’s an adenovirus – the type of virus that normally causes a cold or a flu – that has been engineered so that it does not make you sick. Once you get the injection and the virus is inside your body, its DNA can be read by your cellular machinery to produce spike proteins. As your immune system works to fight these foreign proteins, it will learn to protect you from COVID-19. To learn more about this process view a detailed, interactive piece from the New York Times.

Vaccine Safety

Is the vaccine safe for people with diabetes?

All three currently authorized vaccines – Pfizer-BioNTechModerna, and Johnson & Johnson – appear to be safe and effective for adults with diabetes. Rigorous clinical trials tested the safety of these vaccines in adults of all ages, races, and ethnicities, as well as chronic health conditions.

  • The Pfizer-BioNtech trial included 3,150 people with diabetes (8.4% of trial participants).
  • The Moderna trial included 2,858 people with type 1, type 2, and gestational diabetes (9.4% of trial participants).
  • The Johnson & Johnson trial included 3,389 people with type 1 and type 2 diabetes (7.7% of trial participants).
  • In terms of racial and ethnic diversity, the trials each included more than 20% Hispanic or Latino participants, almost 10% African American participants, and almost 5% Asian participants.

These vaccines were advanced quickly thanks to the immense resources provided for COVID vaccine development – even with a speedy process, the vaccine manufacturers had to follow the typical safety steps and thorough checks. Read more from the CDC about how the vaccines work, potential side effects, and details from the human clinical trials.

Does it matter which vaccine you get?

No – all three of the vaccines will protect you and those around you. However, there are some differences between the vaccines that may be important to people with diabetes.

Clinical trials found both mRNA vaccines to be extremely effective in adults – with almost 95% efficacy overall, only one in 20 people that receives the vaccine would get sick from COVID. Among the trial participants with diabetes, the Pfizer-BioNtech was 95% effective and the Moderna vaccine was 100% effective, while the Johnson & Johnson vaccine was 53% effective. Participants were only followed for a few months, so we don’t yet know the long-term effectiveness of these vaccines. As more vaccines are administered there will be more data collected, and hopefully children will be enrolled in clinical trials soon.

What does it mean for these vaccines to be “effective?” If a vaccine is 50% effective it successfully protects half of the people who receive it from getting infected by COVID-19 if they are exposed. If a vaccine is 75% effective, it protects three out of four people from COVID-19 infection. More importantly, all three vaccines are highly effective at preventing severe COVID-19 infection. All three clinical trials found that in people who did get infected after vaccination, the infection was much milder – among people who had received one of the three authorized vaccines, there were almost no deaths or hospitalizations resulting from COVID-19. To learn more about how the three vaccines compare, watch this video.

During early vaccine distribution, you likely won’t have any choice in which vaccine is available to you because there will be a limited supply and the goal is to vaccinate people as quickly as possible. Both mRNA vaccines require two shots, meaning that they are not considered fully effective until you have received both doses, and your immune system has developed protection against the virus (after the second shot). You should receive two shots of the same vaccine (either Pfizer-BioNtech or Moderna). The Johnson & Johnson vaccine only requires one shot.

Which vaccine is best for people with diabetes?Which vaccine is best for people with diabetes?

Due to the distinct design of each clinical trial, it can be hard to directly compare the three vaccines that are currently authorized in the US. However, based on trial data and information from the vaccine manufacturers, here’s the best information we have on how the vaccines compare.

Vaccine data table

Image source: diaTribe

The data show that no matter which of the currently authorized vaccines you get, getting a COVID-19 vaccine is safe and important for people with diabetes. All three vaccines are highly protective against severe COVID illness and death. Click here to watch an in-depth video explaining how the vaccines compare.

What are the side effects? Can the vaccine be dangerous?

When you receive a vaccine for a particular virus, your immune system builds protection against it. Because your body is creating antibodies and learning how to fight the virus or bacteria targeted by the vaccine, you may experience normal side effects for a day or two – this is similar to getting a flu shot, and people with diabetes should monitor their blood sugar levels and have a sick day management plan ready.

According to the CDC, these are the common side effects of the COVID vaccines – they are similar for people with and without diabetes:

  • Pain, swelling, or redness in the vaccinated arm
  • Fever
  • Chills
  • Fatigue
  • Headache
  • Nausea
  • Muscle pain

These side effects are a result of your immune system preparing to combat a future viral infection – they do not mean that you have gotten sick from the vaccine itself. If your side effects don’t go away, contact your healthcare team.

Severe allergic reactions to the COVID vaccine are rare – you can learn more from the CDC here. If you have ever had an allergic reaction to any vaccine, ask your healthcare professional if you should get the COVID vaccine. If you experience a severe allergic reaction to the first dose of the COVID vaccine, do not get the second dose.

How will the vaccine affect my blood sugar levels?

Because the vaccine can cause symptoms of illness that can lead to high glucose levels, it’s important to carefully monitor your blood sugar levels for 48 hours after you receive your vaccination. Stay hydrated, and make sure to have your sick day plan ready in case you feel ill. So far, people with diabetes seem to be experiencing few side effects and minimal effect on blood sugar levels.

Do diabetes medications affect the vaccine?

At this time there is no information available on drug interactions between the authorized COVID vaccines and other medications – this has not yet been studied. However, it is not anticipated that the vaccine itself would interact with insulin or other standard diabetes medications. Note: it may be helpful to avoid injecting insulin or placing a glucose sensor or pump infusion set in your vaccine injection site for several days after vaccination.

Should I get vaccinated if I have diabetes and other health conditions?

People with complications of diabetes (including heart disease and kidney disease) are at much higher risk of severe illness from COVID-19. If you have other health conditions in addition to diabetes, getting the vaccine is especially important.

What is the AstraZeneca vaccine?

New results from the US clinical trial of the AstraZeneca viral vector vaccine show that the vaccine was 79% effective at preventing symptoms of COVID-19 infection, and fully prevented severe illness and hospitalization in more than 32,000 participants. The two-dose AstraZeneca vaccine is currently authorized in Europe and in other countries, but has not yet been authorized for use in the US. The latest clinical trial results show the vaccine to be both safe and effective.

In early March, several countries briefly paused giving people the AstraZeneca COVID vaccine due to concerns about possible rare side effects, including severe blood clots. However, since the data does not show that the vaccine increases the risk of blood clots, the World Health Organization determined that it is safe and that the benefits of the vaccine outweigh any risks. We look forward to updating this article if the AstraZeneca vaccine receives FDA authorized in the US.

Getting the Vaccine

When will people with diabetes get the vaccine?

In most places across the US, people with type 2 diabetes and obesity will be prioritized in the third group of early vaccination (Phase 1c) – this has already begun in some parts of the country. Type 1 diabetes is not currently considered a high-risk medical condition for this phase. Some diabetes experts believe that if you have type 1 diabetes and any evidence of kidney damageheart disease, or obesity with high insulin doses, it’s a good idea to seek vaccination as soon as possible because you may be at high risk for severe illness if you are infected with COVID-19. To learn about the CDC’s recommended stages of vaccination and where you fall in the vaccine line, read Dr. Francine Kaufman’s “When Can I Get the COVID Vaccine if I Have Diabetes?

How will I know when it’s my turn to get the vaccine?

The distribution of vaccines is the responsibility of each state, and states have different plans for vaccinating people. Most states will use networks within hospitals, healthcare offices, and pharmacies to distribute vaccines to residents. Depending on where you live, you may be asked to get on a vaccine waiting list. Click here to see the state by state report from the Kaiser Family Foundation, including who is currently eligible for vaccination in your state. To learn more about your place in the vaccination line, read Dr. Kaufman’s “When Can I Get the COVID Vaccine if I Have Diabetes?” If you have type 2 diabetes or obesity (a body mass index above 30 – check here), contact your healthcare office to ask when and how you can get vaccinated.

How much does the vaccine cost?

You will not have to pay for the COVID vaccine in the US; it will be given to all US residents for free. That said, some vaccination providers may charge an administration fee for delivering the injection. Ask your healthcare office if there will be any costs associated with your vaccination.

What should I expect at my vaccine appointment?

When you get your COVID vaccine, you’ll receive a paper card that says which vaccine you received, and when and where you received it. You’ll also get a fact sheet (paper or electronic) with more information about the vaccine, its benefits, and its side effects. After you get your injection, you’ll be asked to stay on-site for a short period of time so that healthcare professionals can monitor your body’s reaction.

I had COVID-19 – should I still get vaccinated?

Yes – though you can wait up to 90 days after initial onset of your COVID-19 infection. Researchers don’t know how long immunity against the virus can last after natural infection, though evidence suggests that you’re not likely to get sick with COVID again for the first 90 days. You should still get vaccinated for longer-term protection, and the CDC says that you can wait 90 days after the infection before getting your vaccine.

If I have symptoms of COVID-19 now, should I get the vaccine?

If you recently tested positive for COVID-19, are currently experiencing symptoms, or were exposed to someone with COVID, please stay away from other people.

  • If you test positive for COVID, wait until you’ve recovered (as early as 14 days from infection) and up to 90 days before getting the vaccine.
  • If you are experiencing symptoms of COVID, self-isolate and get tested.
  • If you were exposed to someone with COVID, quarantine for 14 days and monitor yourself for symptoms. Get a COVID test. If you do not get sick and your test is negative, get vaccinated once your quarantine period is over.

After Receiving the Vaccine

What happens after I get the vaccine – can I still infect people with COVID?

Once you have received both doses of the vaccine, it should protect you from getting sick with COVID. However, researchers don’t know whether you may be able to carry the virus (without symptoms) and pass it on to others. That’s why it’s still important to maintain safety measures even after receiving the vaccine: wear a face mask that fits you well if you’re in public, avoid contact with people not in your household, social distance from others, wash your hands, and monitor your health. Continuing to follow these measures will help you protect others and your community.

Can I see people now that I am vaccinated?

Two weeks after your final vaccine dose (one dose for Johnson & Johnson, two doses for Pfizer-BioNTech or Moderna) you are considered to be fully vaccinated and protected against severe COVID-19 infection. According to new CDC guidelines, people who are fully vaccinated:

  • Can gather indoors with others who are fully vaccinated, with no need to wear a mask.
  • Do not need to quarantine, stay away from others, or get tested if exposed to someone with COVID – unless you begin to show symptoms of illness.

The CDC also says that people who are fully vaccinated can “visit with unvaccinated people from a single household who are at low risk for severe COVID-19 disease indoors without wearing masks or physical distancing.” However, people with diabetes have a higher risk of getting severely ill from COVID-19 (though there’s no greater chance of being infected). For this reason, even if you are vaccinated, please continue to be cautious.

Is one dose of the COVID vaccine effective?

For the Johnson and Johnson vaccine, yes.

For the Pfizer-BioNTech and Moderna vaccines, not entirely. Results from the clinical trials (Pfizer-BioNTechModerna) show that one dose of the vaccine can offer some protection, but two doses of both authorized vaccines are required for full efficacy.

Does the vaccine protect against the new variant of COVID?

Probably, but not certainly. Researchers are still studying the newest variants of COVID-19 to determine how effective current vaccines are at protecting against them. So far, much of the virus structure is unchanged in the variants and the currently-authorized vaccines seem to produce antibodies that recognize variants of COVID-19. Other strains of COVID will likely develop with time (similarly to the flu), and the vaccines can then be tweaked to match the changed threat. Click here to learn more about COVID variants, how they work, and what you can do to protect yourself.

Can I get COVID from the vaccine?

No. The vaccines do not contain the live virus, so they cannot infect you with COVID-19. Side effects that appear after you receive the vaccine occur because your immune system is activating and building antibodies – they are not signs of infection.

After vaccination it takes time for your body to develop full immunity to the virus, so it is still possible to get infected with COVID in the days before or after your vaccination. This does not mean the vaccine did not work; rather, it means that your immune system did not have enough time to build full immunity from the vaccine before coming into contact with the virus.

Are other vaccines coming?

To date, 13 vaccines have been approved for full or limited use around the world. Seventy-eight vaccines are currently in different stages of human clinical trials: 55 are in the early stages and 23 are in the final stages of testing. Hopefully, some of these vaccines will be found to effectively protect against COVID, opening up more vaccination options for people around the world. To track global vaccine development, view the New York Times Coronavirus Vaccine Tracker.

When can I stop wearing a mask?

Even after you get the vaccine you should still wear a face mask whenever you are in public places. Masks will continue helping to shield you from the virus and new variants of COVID (since no vaccine is perfect), and will reduce your chances of spreading COVID-19 to people around you (if you are carrying the virus and don’t have symptoms). As more people get vaccinated, the number of people carrying the virus in your community will decrease, bringing the risk of infection down. Public health authorities will make announcements about this, which may vary from place to place and even with the season.

If you are fully vaccinated, you can begin spending time with others who are fully vaccinated without wearing face masks.

While we await further information and research on COVID vaccines, protect yourself and those around you. For more information, read “Staying Safe – And Staying Well – During a Pandemic Winter” and “COVID Variants, Double Masks, Diabetes, Oh My!

Editor’s note: This article was first published on January 8, 2021, and last updated on March 22.

Dr. Francine Kaufman is Chief Medical Officer at Senseonics, a diabetes device company and Distinguished Professor Emerita of Pediatrics and Communications at the Keck School of Medicine, University of Southern California.

Source: diabetesdaily.com

Was Your Medicare Claim Rejected? Here’s How to Appeal

This content originally appeared on diaTribe. Republished with permission.

By Kara Miecznikowski and Eliza Skoler

Learn how to appeal a Medicare claim rejection under traditional fee-for-service Medicare, a Medicare health plan, or Medicare prescription drug coverage

A health insurance claim is a bill for your healthcare services, medications, or medical equipment that you think should be covered by your insurance plan. If you have Medicare health insurance, your healthcare practitioner will usually submit claims directly to Medicare for payment. If Medicare decides to reject the claim, you can challenge the decision. This is called an appeal.

In the United States, people have the right to appeal a denied claim for up to six months after hearing about this decision. Appeals can often be successful – a 2018 report showed that 75% of Medicare Advantage denials were overturned in the appeals process – which means that challenging a denied claim could save you money. This article will explain how to appeal a Medicare claim rejection.

To learn more about the appeals process in the United States – especially if you have a different health insurance plan – read our article, “When Insurance Gets Turned Down: Appeals Explained.”

How do Medicare appeals work?

You can appeal a decision made by the national Medicare fee-for-service program (Parts A and B), your private Medicare health plan (Part C), or your Medicare Prescription Drug Plan (Part D). Learn more about the different types of Medicare here.

Click to jump down to:

Appeals under Medicare Part A or B (“Original Medicare”)

Appeals under Medicare Part C (Medicare Advantage health plan)

Appeals under Medicare Part D (prescription drug plan)

Here are some common situations for appealing a claim rejection:

  • If you have already received the service, medication, or medical supplies. Example: your doctor gives you lab tests during a visit, but then Medicare rejects the claim.
  • If your doctor requested the service, medication, or medical supplies for you. Example: your doctor says you need an insulin pump and Medicare decides that is not medically necessary.
  • If you and your doctor request a change in price for your medication, based on what treatments work for you. Example: generic drugs do not work for your condition, so your doctor asks for a discount on the more expensive drug.

The appeals process is different under Medicare Part A, B, C, or D. There are five levels to the appeals process. If you disagree with the appeal decision at level one, you can continue to appeal the decision again at every other level.

With each appeals processes, write your Medicare number on every document you submit for your appeal, and keep a copy of all the materials you send in.

Filing an appeal under Medicare Part A (hospital insurance) or Part B (medical insurance), often called “Original Medicare:”

  • Your bill will be sent directly to Medicare.
  • The appeal must be filed within 120 days of receiving the Medicare Summary Notice (MSN) that shows that your claim was denied.
  • If you disagree with a Medicare coverage decision in the MSN, you can appeal the decision.

A Medicare Summary Notice (MSN) is a summary of the health care services you have received over the past three months, sent to you by mail.  It shows what Medicare paid for each service and what you owe for the service, and it will show if Medicare fully or partially denied a medical claim. The MSN also contains your appeal rights and step-by-step directions on when and how to file an appeal for a claim rejection.

Did you sign an Advanced Beneficiary Notice of Noncoverage (ABN) before you received the treatment? An ABN is a notice that your healthcare provider will give you if they think the health services they are recommending might not be covered by Original Medicare. Your ABN will list the items that Medicare is not expected to pay for, as well as the estimated costs of those health services. The ABN can help you decide if you would still like to receive the treatment, and if you will pay for it if Medicare declines to cover the cost.

When you sign an ABN you can ask your healthcare provider to submit the claim to Medicare (before billing you), asking Medicare to cover the cost. If Medicare rejects the claim, you can appeal the decision. If your healthcare provider did not give you an ABN before treatment, you might not be responsible for paying for the health service. Learn more ABNs and appeals here.

There are three different ways to file an initial appeal under Original (Part A or B) Medicare:

appeals

Image source: iStock Photo

  • Fill out a “Redetermination Request Form” with information from your MSN; send the form to the address provided on your MSN
  • Follow instructions on your MSN for filing an appeal without using the form:
  1. Circle the claim that you disagree with on your MSN
  2. On a separate piece of paper, explain why you disagree with the decision
  3. Write your name, address, phone number, and Medicare number on the MSN, and sign it
  4. If you have any other information that will support your case, include it; you can ask your doctor or other health care provider to help you
  5. Send all of the above materials to the address listed under “Appeals Information” on your MSN
  • Or, send a written request to the company that processes Medicare claims. Include:
  1. Your name and Medicare number
  2. The item that you disagree with on the MSN
  3. An explanation of why you disagree with the decision
  4. Your signature
  5. Send all of the above to the address provided under “Appeals Information” on the MSN

You should receive a decision within 60 days of your request, unless you submit extra information after you first file the appeal (which may delay the decision).

For more information on the Original Medicare initial appeals process, see the Medicare webpage. If you disagree with the appeal decision at the first level, you have 180 days to file an appeal at the second level; information on the appeals process beyond level one can be found here.

Filing an appeal under Part C (Medicare Advantage health plans):

  • The initial appeal must be filed within 60 days of receiving the claim rejection.
  • You must send a written request (unless your plan allows you to file a standard request by phone, fax, or email instead).

In your request, include:

  1. Your name, address, and Medicare number
  2. The item you disagree with, the date that you received the service, and an explanation of why you disagree with the decision
  3. Any other information that may support your case

You should receive a decision about your appeal within 60 days, unless Medicare needs more time to obtain information from your healthcare provider. If waiting for a decision will hurt your health, your appeal decision will be made within seven days.

If your appeal is rejected (fully or partially), your request will automatically be sent to level two of the appeals process. More information on the initial appeals process under Medicare Part C can be found here. For information on the process after level one, click here.

Filing an exception request or appeal under Medicare Part D (prescription drug plans):

  • Reasons to request an exception to your Part D drug plan:
    • If your plan decides not to provide a medication you think should be covered.
    • If cheaper versions of your medication don’t work for you, you can ask for a discount on the more expensive medication.
    • If a drug you need is not on your plan’s drug list, you can ask for an exception.
  • An exception request must be submitted first; if your exception request is denied, you have 60 days to appeal the prescription drug claim rejection.
  • You must send a written request (unless your plan allows you to file it in another way).

An “Evidence of Coverage” document explains your rights with your Medicare prescription drug plan. You have the right to ask your plan to pay for a medication you think should be covered, and you have the right to request an appeal if you disagree with your plan’s decision to provide it.

appeals

Image source: iStock Photo

Before appealing a claim rejection, you will request an exception:

  1. Fill out a Medicare Prescription Drug Coverage Determination request form through your insurance plan sponsor
  2. Ask the healthcare provider who prescribed your medication to write a letter explaining why you need this medication
  3. Send the documents to your Medicare health plan

You should hear back about your request within 72 hours. If your exception is denied, you can appeal the claim rejection. To submit a written appeals request, include:

  1. Your name, address, and Medicare number
  2. The drug you want your plan to cover
  3. An explanation of why you are appealing the coverage decision.
  4. Any other information that may support your case, including medical records
  5. Send the documents to your Medicare health plan

You should receive a decision within seven days. If waiting for a decision will hurt your health, your appeal decision will be made within 72 hours.

More information on the initial prescription drug appeals process can be found here. If your request is not met (fully or partially), you have 60 days to appeal the decision at the next level; learn about further appeals here.

How can I get help filing an appeal?

You can have someone else file an appeal for you. This can be a family member, friend, lawyer, doctor, or anyone else that has agreed to be your representative. For more information and the representative form, see the Medicare website page on how to appoint a representative. For prescription drug appeals, your doctor or prescriber can request an initial appeal for you; you do not need to first fill out a form.

For more help with appeals, especially appeals beyond level one, contact your State Health Insurance Assistance Program (SHIP). SHIP is a network of free counseling services that help people navigate Medicare; find the SHIP program in your state here.

diaTribe Series

Image source: diaTribe

This article is part of a series on access that was made possible by support from AstraZeneca. The diaTribe Foundation retains strict editorial independence for all content. 

Source: diabetesdaily.com

Prior Authorization: Getting Diabetes Supplies and Medications Covered by Insurance

This content originally appeared on diaTribe. Republished with permission.

By Divya Gopisetty

What is a prior authorization? Read on to learn more about why diabetes supplies or medications might require a prior authorization and how to go through the process

It can be frustrating to learn that you need a prior authorization when you already have a prescription. Insurance plans sometimes require a prior authorization to cover a diabetes supply, device, or medication, even if your doctor prescribed it to you.

Read on to learn about what a prior authorization is, and how you can make the submission process as smooth as possible.

In this article:

Click to jump to a specific section!

What is a prior authorization?

My pharmacist told me I need a prior authorization. What happens next?

How can I check if I need a prior authorization?

How long do prior authorizations last?

What happens if the prior authorization is denied?

What is a prior authorization?

A prior authorization, also known as a pre-authorization or pre-certification, means that your healthcare provider or device company has to get specific approval from your health insurance company (so that it will pay for it).  The requirements for prior authorization differ between and within insurance plans.

If you need a prior authorization, the pharmacist cannot process your prescription until your healthcare professional has contacted the insurance company. Similarly, a device company may not ship your diabetes device to you until it has prior authorization from the insurance company.

A prior authorization is designed to make sure certain prescription drugs or devices are used correctly and only when medically necessary. Before your insurance plan will cover a certain device or drug, you must show that you meet a set of criteria.

Prior authorizations are most often handled by your healthcare professional’s office, but sometimes are handled by the device company itself (e.g., for CGM).

If you want to see what a prior authorization request form looks like, check out this one for OptumRx.

My pharmacist told me I need a prior authorization. What happens next? 

  1. If your insurance company requires (and has not received prior authorization), your pharmacy will contact your healthcare professional.
  2. The healthcare professional will contact your insurance company and submit a formal authorization request.
  3. Your insurance plan may have you fill out and sign some forms.
  4. Your insurance plan will contact the pharmacy once it has approved or denied the request.

During this process, be sure to communicate with both your healthcare provider and your insurance company to see if they need any additional information. Prior authorizations usually take about a week to process – after that, check with your pharmacy to see if the request was approved. If the request was approved, you should be able to pick up your prescription from the pharmacy.

If it wasn’t approved, your pharmacy should be able to tell you why, and then you can decide to request an appeal.

As someone living with diabetes, you are your best advocate. Be prepared to track down the paperwork to make sure you receive the requested device or medication.

How can I check if I need a prior authorization?

Check your health plan’s policy and formulary (you can normally access these on the insurance company’s website) to see if any of your treatments require a prior authorization. Or, you can call the member services number found on the back of your insurance ID card to speak with someone directly.

How long do prior authorizations last?

Most approved prior authorizations last for a set period of time (usually one year). Once it expires, you’ll have to go through the prior authorization process again.

What happens if the prior authorization is denied?

  • You can request an appeal (which is often successful!)
  • You can pay the full cost for the medication or healthcare supply, without insurance coverage.

Want to learn more?

Check out this easy-to-read resource created by DiabetesSisters on prior authorizations, step therapy, and appeals.

What’s Worked for Other People with Diabetes? Hear from Them!

  • I was denied my first CGM in 2008 by a Blue plan and fought and won by knowing how to Google my payer’s medical policy and prove that I met coverage criteria. It helped that I was given the HCP line phone number by a nurse sympathetic to my cause, but I ended the call with an authorization code. – Melissa
  • My strategy has always been persistence pays (eventually the insurance company will give in, although they may have peculiarities to navigate. The doctor’s office is really key and many have specialists who only deal with insurance company issues [mine does]). I’ve been covered by 4 insurance companies over the past decade while at the same employer if that tells you anything about the evolving insurance market. My experience with Anthem was a hassle but predictable, United Healthcare was easiest to navigate, Aetna was straightforward but a pain and had some weird rules (Why does a precertification inexplicably expire at the end of a calendar year? My chronic illness did not expire at the end of the year.). – Scott
  • Do you have experiences with prior authorizations? Let us know!
diaTribe Series

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This article is part of a series on access that was made possible by support from AstraZeneca. The diaTribe Foundation retains strict editorial independence for all content. 

Source: diabetesdaily.com

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