Insurance Navigation Guide - Type 1 Diabetes

🚨 If You're Uninsured

Medicaid: Check eligibility in your state
CHIP: Children's Health Insurance Program
Marketplace: Healthcare.gov for ACA plans
Manufacturer Programs: Many offer patient assistance
Local Resources: Check with diabetes organizations

📋 Understanding Your Coverage

Key Terms to Know:

Deductible: Amount you pay before insurance kicks in
Copay: Fixed amount you pay for each service
Coinsurance: Percentage you pay after deductible
Out-of-pocket maximum: Most you'll pay in a year
Prior authorization: Insurance approval needed for certain supplies

💊 Covered Supplies (Usually)

Blood glucose meters and test strips
Insulin and syringes/pen needles
Lancets and lancing devices
Ketone test strips
Glucagon emergency kits
CGM systems (with prior authorization)
Insulin pumps (with prior authorization)

📞 Questions to Ask Your Insurance

What's my deductible and out-of-pocket maximum?
Do I need prior authorization for CGM/pump?
Which pharmacies are in-network?
What's the copay for diabetes supplies?
Are there quantity limits on test strips?
Do I need a referral to see an endocrinologist?
What's covered for diabetes education?

📝 Prior Authorization Process

Get prescription from your doctor
Submit to insurance with medical justification
Wait for approval (usually 5-10 business days)
If denied, appeal with additional documentation
Work with your doctor to provide more details

✅ Appeals Process

If your claim is denied:

Request written explanation of denial
Gather medical records and doctor's letters
Submit formal appeal within deadline
Consider external review if internal appeal fails
Get help from patient advocacy groups

💰 Cost-Saving Tips

Use generic insulin when possible
Buy supplies in bulk (90-day supply)
Compare prices at different pharmacies
Use manufacturer coupons and programs
Consider mail-order pharmacy
Ask about patient assistance programs

📞 Important Phone Numbers

Your Insurance: _________________

Member ID: _________________

Group Number: _________________

Pharmacy Benefits: _________________

Prior Authorization: _________________

📋 Annual Checklist

Review plan changes during open enrollment

Check if your doctors are still in-network

Verify covered supplies haven't changed

Update prior authorizations if needed

Review out-of-pocket costs and budget

💡 Remember

Insurance can be complicated, but you have rights. Don't give up if something is denied - appeals often work. Your diabetes team can help you navigate the system.