Insurance coverage

Getting insurance coverage for the latest medical technologies isn’t always easy

“It’s something we were really looking forward to,” he said.

Last month, the Salls received the email from the manufacturer of the pump they had been waiting for: “We are delighted to announce that ‘the new pump (called Omnipod 5)’ can now be prescribed by your doctor. We We’re glad that day has come.

Soon, Cate’s endocrinologist at Baystate Medical Center in Springfield wrote the prescription. (The Salls family lives in the town of Sunderland, in western Massachusetts.)

Then the problems started.

On May 23, the Salls received a voicemail from the endocrinologist’s office: “It appears that when we checked insurance eligibility, they are telling us that the Omnipod 5 is still an exclusion from the plan.”

Daniel Salls said he immediately called his family’s health insurer, Point32Health (which is the name of the company after Harvard Pilgrim Health Care and Tufts Health Plan merged), to challenge the exclusion.

But Daniel said the conversation ended without him feeling satisfied as to why the pump wasn’t covered. That’s when he wrote to me, which led me to ask Point32Health about “plan exclusion”, which is a provision of an insurance policy that eliminates coverage for certain things.

Point32Health replied to me without mentioning “the exclusion of the plan”. Instead, he said the pump in question “is not currently available for prescription as it is in limited release on the market and not available to the general public.”

Elizabeth Salls smiles at her daughter Cate.Chris Marion Sr for the Boston Globe

Once the Omnipod 5 System is available for prescription, Point32Health will “fully evaluate it” “for policy and coverage decisions,” the email said. It seemed to me like a recipe for more delay.

Later that day, the Salls received an unexpected call from their insurer giving them a “prior authorization” number, along with instructions to give it to their endocrinologist.

Prior authorization, in health insurance lingo, generally means approval of coverage, as opposed to “exclusion from the plan.”

“Fingers crossed we’ll see tomorrow where another three hours on the phone takes us,” Daniel told me in a text, with a slight exaggeration. He also said he thought my involvement may have played a role: “There was a definite shift in the tone and tenor of our interactions with them as the day went on.”

The next communication I received from Point32Health, in response to further questions, said, “We are reviewing applications for this product and approving when medically necessary. Now we have to wait for it to become available. »

This seemed like a step up from the earlier, bureaucratic-sounding statement about the need 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.

A spokesperson for Insulet responded, “With a limited distribution network, any physician can write a prescription and any patient who has access and insurance coverage can obtain our product. They just have to go through a pharmacy that they may not be going to now.

The same day I received this explanation, Daniel called Optum Rx, a prescription drug provider, which is an approved provider under the Salls health care plan. Optum Rx said it has the Omnipod 5 and could ship it to them once Point32Health approves, Daniel said.

When I asked Point32Health for an explanation of the original denial, he said, “There were several contributing factors to this. Since the product is new and, according to the manufacturer, not yet widely available, it has been coded into the system in the same way as the Omnipod DASH product (legacy device), which was free from the manufacturer. We generally exclude coverage for products that are offered free of charge by a manufacturer. »

At the end of the line ? “We have instructed Optum Rx to ship the product to the member as soon as possible”, Point32Health said.

Last Wednesday, he arrived at the Salls.

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 full of pitfalls and dead ends.

I’m sure no harm is intentional, but sometimes misinformation is spread about what’s covered and what’s not. Savvy consumers know to keep going.

Consumers are generally at a great disadvantage when dealing not only with insurers, but also with providers and medical suppliers. Sometimes what they say is confusing and contradictory. Sorting it all out can be exhausting and daunting.

At this point, the Salls know how to persist. But of course, not everyone has the time and ability to do what the Salls say they do on a regular basis.

A better, more streamlined system is needed.


I have a problem? Send your consumer concern to sean.murphy@globe.com. Follow him on Twitter @spmurphyboston.