Insulin, CGMs and supplies: comparing FEHB plans

Why premiums tell you nothing here

For most people the premium and the deductible decide the year. If you or a family member has diabetes, recurring supply costs dominate, and they are set by details buried in the brochure rather than by anything on the comparison page.

The four that move real money: which insulin is on the formulary and at what tier, whether a continuous glucose monitor runs through the pharmacy or the medical benefit, what prior authorisation is required, and whether mail order is cheaper.

The CGM question

This is the one that catches people out. A continuous glucose monitor can be covered two completely different ways:

• As a pharmacy benefit: sensors are dispensed like a prescription, and you pay a copay per supply period.
• As durable medical equipment under the medical benefit, where you pay coinsurance, often a percentage, and the deductible may apply first.

On an ongoing supply, a fixed copay and a percentage of the full cost are not close. Ask the plan directly, by brand name: is this device covered under pharmacy or under DME, and what do I pay in each case?

Insulin and the formulary

• Find your exact insulin on the plan's formulary, including the concentration and the delivery form. Vials and pens are often on different tiers.
• Check the tier, not just whether it is listed. Preferred brand and non-preferred brand can differ substantially per fill.
• Check for a cap. Some plans cap the cost-sharing on insulin per month; where that exists it may matter more than the deductible.
• Check whether the deductible applies to prescriptions at all. In some plans drugs sit outside it; in others, especially HDHPs, they do not.
• Mail order for 90 days is frequently cheaper per month than retail. Check the ratio rather than assuming.
• Specialty pharmacy rules can require a particular dispenser. That is a real constraint, not a suggestion.

Pumps, strips and the rest

• Insulin pumps are usually DME, with coinsurance on a substantial purchase price, plus ongoing supplies that may be billed separately.
• Test strips and lancets may have quantity limits per month regardless of how often you test.
• Diabetes self-management education is covered by many plans and underused.
• Prior authorisation on devices and newer drugs is common. Find out before you switch plans, because an authorisation does not travel with you.
• The catastrophic limit is the number that caps a bad year. On a chronic condition, check it carefully; it is often more important than the deductible.

Comparing plans properly

• Write down your actual year: each prescription with dose and quantity, each device and its supplies, and your usual appointments.
• Price that list against two or three plans, using each brochure's pharmacy section and the formulary.
• Add the premium last. Supply costs usually dwarf the premium difference.
• Call the plan before Open Season closes and ask the CGM question by brand. Get the answer in writing where you can.
• Check your endocrinologist is in network for the specific option, not just the carrier.
• If a claim is denied later, the appeal deadlines are strict: six months to the carrier, then 90 days to OPM.

HDHPs and diabetes

A high-deductible plan with an HSA can still work with a chronic condition, but the arithmetic is different. Preventive drug lists matter, because some HDHPs cover certain maintenance medicines before the deductible, and some do not.

If your supplies run into the thousands each year, you are likely to meet the deductible early every year. That makes the comparison a question of total cost including the premium and the plan's contribution to the HSA, rather than a question of risk. How HDHPs and HSAs actually work is here.

Common questions