When you’re caring for a child with diabetes, navigating insurance issues can be a challenge. Social workers and diabetes nurses at CHOP’s Diabetes Center for Children are available to help with insurance coverage and financial concerns.
If you're unable to get an A1C done at CHOP:
- The CHOP lab may be out-of-network.
- Ask your primary care doctor (PMD) if he can make a referral to CHOP’s lab.
- If you can’t get a referral to CHOP’s lab, ask your primary care doctor to do an A1C a week before your diabetes visit.
- Make sure your PMD forwards your A1C results to your diabetes nurse or bring the results with you to your visit.
- results with you to your visit.
If your insurance won’t cover blood sugar test strips at the pharmacy:
- Call the “Member Services” phone number on your insurance card. Ask how test strips are covered. They may be covered under a “Durable Medical Equipment (DME)” benefit, not a pharmacy benefit. You need to get your strips, lancets and syringes through a Durable Medical Equipment supplier. Ask “Member Services” for DME suppliers. (You may have to make a mail order request).
- If you do have to pay for strips out of pocket, save your receipts. Call Member Services for help to submit them for reimbursement.
If your child’s insulin pens are no longer covered by insurance:
- Your insurance may not cover insulin pens. Insulin pens are more expensive than syringes. Many insurance companies cover the cheapest medication or device to keep costs down.
- Contact your diabetes nurse. She will make a request for prior authorization. She gives reasons why the insurance should cover expensive insulin pens for your child. When this works, you get a 3-6 month approval for pens.
- Call the insurance company yourself. Advocate for your child. Ask for a case manager to be assigned to your case so that you are talking to the same person every time.
If your insurance company won’t pay for enough test strips each month:
- Your nurse needs to get prior authorization to get more test strips. She may have to get prior authorization every time you get strips. You may have to prove you are using the strips. Some insurance companies require computer downloads of your meter or blood sugar logs to justify the extra test strips.
If your insurance company won’t cover an extra bottle of insulin to keep at school:
- Talk to your diabetes nurse. She will contact your insurance company to request an extra bottle of insulin through a prior authorization.
If you lose your job and cannot afford COBRA payments to keep your child with diabetes insured:
- Contact your diabetes social worker at 215-590-3174. She will refer you to CHOP’s Family Health Coverage Program (FHCP).
- FHCP staff will help you apply for state health insurance for your child. They will also inform you if you are eligible for other programs that can assist you with the costs of prescriptions and diabetes visits.
If your insurance claim is denied despite the diabetes team’s intervention:
- Review your insurance policy or employee benefits to find out your appeals rights, then make an appeal. You may need to file a written appeal and provide information from your doctor supporting your dispute.
- If you are dissatisfied after appeals through your insurance policy, contact your State Insurance Department. Below is contact information for the tri-state insurance departments: