People living with Type 1 diabetes must take insulin by injection or infusion every day. Insulin is life support – we all need it to stay alive, as much as we need oxygen, water, and food to eat. Without access to insulin, nothing else we do here at Beyond Type 1 matters. Unfortunately (and alarmingly) many people living with T1D in the United States and around the globe do not have reliable access to affordable insulin.

If you live in the United States and you’re struggling to pay for this month’s refill, you’ve come to the right place. If you haven’t already, we urge you to find your personal insulin access Action Plan by inputting your information here.

You can also explore tools + actions you can take to get involved with access advocacy here.

If you need insulin

If you are in emergency need of insulin within the next 7 days, get urgent insulin support here. The below resources address those struggling to access insulin on an ongoing basis. 

Manufacturer Patient Assistance Programs

You are most likely eligible for a PAP if you do not have private insurance, do not qualify for Medicaid, and make less than 400% of the federal poverty level. They provide insulin for $0 out of pocket for up to 12 months for those who qualify.)

If you take Lilly insulin (Humalog, Basaglar, Lyumjev) and are uninsured or have Medicare Part D and meet certain income parameters, you may be eligible for free insulin through the Lilly Cares Foundation Patient Assistance Program, aka Lilly Cares. Call Lilly Cares Foundation at 1-800-545-6962 between 8am and 6pm Eastern Time, Monday through Friday or complete the online application here.

If you take Viatris (formerly Mylan) insulin (Semglee) you may qualify for the Mylan Patient Assistance Program. If so, your insulin could be free for up to 12 months. Call the Mylan Customer Relations team at 800-796-9526. They can email, fax, or mail the application to you.

If you take Novo Nordisk insulin (Fiasp, NovoLog, NovoRapid, Levemir, Tresiba) the NovoCare Patient Assistance Program provides free insulin to those who qualify, which is limited to those with no private insurance and who do not qualify for federal insurance programs and who are at or below 400% of the federal poverty level – with a few exceptions. You can download an application here or have an application mailed to you by calling 1-866-310-7549 between 8am and 8pm Eastern, Monday through Friday.

If you take Sanofi insulin (Admelog, Lantus, Toujeo, Apidra, Soliqua) the Sanofi Patient Connection Program provides Sanofi insulins to those who qualify, which is limited to those with no private insurance who do not qualify for federal insurance programs and who are at or below 400% of the federal poverty level – with a few exceptions (such as certain instances of those covered by Medicare Part D). Download an application here or have an application mailed to you by calling 1-888-847-4877 between 9am and 8pm Eastern.

Copay Cards + Cash Payment Programs

Copay cards reduce the out-of-pocket cost you pay at the pharmacy exist for most insulins. Unfortunately, copay cards are typically not available for those insured through Medicaid or Medicare. Details on current specific copay programs are below.

If you take Lilly insulin (Humalog, Basaglar, Lyumjev) and do not have health insurance OR are covered by commercial/private insurance (including high deductible health plans), you may be eligible for Lilly’s Insulin Value Copay Card, which provides insulin at $35 per month for each Lilly insulin product. Click here to download your card. If the pharmacy has trouble processing your Lilly Insulin Value Program Savings Card, make sure they have called the pharmacy help line at 1-800-282-4888.

  • If you have private insurance, you may also be eligible for a variety of copay card savings programs that may bring your cost down to as little as $5 to 25 per month, depending on the type of insulin(s) you take. All options can be found by entering your information here to build your personalized insulin access Action Plan.

If you take Mannkind insulin (Afrezza) and your private insurance covers Afrezza, you can sign up for the Savings Program, which may lower copays for those with private insurance.

If you take Viatris (formerly Mylan) insulin (Semglee) you may be eligible to use the Semglee Savings Card. This card may help you pay as little as $0 per 30-day prescription for up to a maximum savings of $75, based on your insurance. Click here to download this Semglee Savings Card. For questions regarding the Semglee Savings Card, call 800-657-7613 between 8am and 8pm Eastern, Monday to Friday.

If you take Novo Nordisk insulin (Fiasp, NovoLog, NovoRapid, Levemir, Tresiba) and have no health insurance, have or are eligible for Medicare Part D, or are covered by commercial/private insurance (including high deductible health plans), you are eligible for Novo Nordisk’s My$99Insulin cash program, which allows for the purchase of up to three vials or two packs of insulin pens, of any combination of insulins from Novo Nordisk Inc., for $99 per month.If you have private insurance, you may also be eligible for a variety of copay card savings programs that may bring your cost down to as little as $5 to 45 per month, depending on the type of insulin(s) you take. All options can be found by entering your information here to build your personalized insulin access Action Plan.

If you take Sanofi insulin (Admelog, Lantus, Toujeo, Apidra, Soliqua) and do not have prescription medication insurance, you are eligible for Sanofi’s Insulins ValYou Savings Program, which offers any combination of most Sanofi insulins for $99 per month. This program offers up to 10 boxes of pens and/or 10 mL vials (which can be a mix of long-acting and short-acting as needed) per month.If you have private insurance, you may also be eligible for a variety of copay card savings programs that may bring your cost down to as little as $0 per month, depending on the type of insulin(s) you take. All options can be found by entering your information here to build your personalized insulin access Action Plan.

If you are in emergency need of insulin within the next 7 days, get urgent insulin support here.

 

 

Insulin is a hormone produced in the pancreas that regulates the amount of glucose in the blood, effectively turning food into fuel for the body.

A person is diagnosed with diabetes once the body is no longer able to produce insulin (type 1 diabetes, caused by an autoimmune attack or malfunction) or able to produce enough insulin (type 2 diabetes, caused by metabolic disorder) to regulate blood sugar levels in a healthy way. Diabetes can develop at any age, and can even happen just during pregnancy (known as gestational diabetes).

A brief history of insulin

In 1921, Frederick Banting and his assistant Charles Best discovered how to remove insulin from a dog’s pancreas. They then used the insulin to save the lives of other animals, and eventually humans suffering from diabetes. Before insulin was discovered, people with diabetes were placed on a “starvation diet,” which just delayed death.

Insulin from cattle and pigs was used for many years, but it caused allergic reactions in many patients. The first synthetic “human” insulin was produced in 1978 utilizing E. coli bacteria in its production. In 1982, Eli Lilly began selling Humulin R/Regular and N/NPH, the first commercially sold biosynthetic human insulins.

Insulin Today

Insulin now comes in many forms. It is important to know the difference and to be aware of the various qualities that set them apart. If you are switching types of insulin because of insurance coverage, cost, or provider recommendation, it is important to learn the differences so that you know how to accurately dose your insulin and stay safe.

There are several types of insulin today: Rapid-acting, Short-acting, Intermediate acting, Long-acting, Ultra Long-Acting, and Inhaled insulin. They are categorized by how quickly they begin to work in the blood stream and also how long their effects will last.

They are produced by several companies, including what is known as “The Big Three” in the US: Ely Lilly, Novo Nordisk, and Sanofi. Other companies such as Mannkind and Mylan also sell insulin in the US market. Each company has their own brand of insulin within each of the categories below.

For many people, insulins within the same category (rapid-acting, etc.) can be interchangeable, but this is not true for all. It is important to work with your healthcare provider to determine the right insulin for you.

Editor’s note: visit our US Healthcare Glossary for a deeper dive on the healthcare coverage system in the US.

A note on biosimilars

Biosimilar insulins, the generic form of the biosynthetic insulins currently on the market, are becoming more available as FDA approval pathways are streamlined within the US. It is currently unclear as to whether or not the availability of biosimilars will decrease the cost of insulin in the US.

Several manufacturers in the US are currently offering “generic” versions of their current insulins at a lower price. Other biosimilar companies may begin to enter the US market within the next few years.

Ultra rapid-acting insulin

  • Currently comes in two forms:
    • Fiasp (bolused or injected)
    • Afrezza (inhaled)
  • Taken as a bolus or inhaled before or during a meal or to correct for high blood glucose
  • Takes effect in 15 minutes
  • Fiasp lasts 2 to 4 hours, Afrezza lasts 1.5 to 3 hours
  • Brand names: Fiasp (aspart, with Vitamin B3 to make it ultra rapid), Afrezza (inhaled)

Rapid-acting insulin

  • Taken as a bolus before or during a meal or to correct for high blood glucose
  • Takes effect in 15 minutes
  • Lasts 2 to 4 hours
  • Brand names: Apidra (glulisine), Humalog (lispro), Admelog (lispro), Lyumjev (lispro-aabc), Novalog or Novorapid (aspart)

Short-acting insulin

  • Taken as a bolus before or during a meal or to correct for high blood glucose
  • Takes effect in 30 minutes
  • Lasts 3 to 6 hours
  • Brand names: Humulin R (insulin Regular human), Novolin R (insulin Regular human)

Intermediate-acting insulin

  • Usually taken twice a day as a combination bolus and basal insulin
  • Takes effect in 2 to 4 hours
  • Lasts 12 to 18 hours
  • Brand names: Humulin N (Insulin NPH), Novolin N (Insulin NPH)

Long-acting insulin

  • Taken once or twice a day as a basal insulin
  • Takes effect in 2 to 4 hours
  • Lasts 24 hours
  • Brand names: Lantus (glargine), Semglee (glargine), Levemir (detemir), Basaglar (glargine)

Ultra long-acting insulin

  • Taken once a day as a basal insulin
  • Takes effect in 6 hours
  • Lasts 36 hours
  • Brand names: Toujeo (glargine), Tresiba (degludec)

 

 

This Health Insurance Guide was originally created by JDRF, and is summarized here as part of the JDRF – Beyond Type 1 Alliance.


 

When you have health needs due to a chronic condition like diabetes, having health insurance is critical in helping you manage and treat your condition. Our aim is to help you understand your coverage options — that way you spend time where it matters, on you and your family. In this guide, we’ll provide information on several key areas you’ll want to consider as you select and then use your health insurance plan.

Choosing a plan

Choosing an insurance plan for diabetes involves asking the right questions. First thing’s first: timing is extremely important when dealing with insurance. If you have health insurance through your employer, ask HR about open enrollment dates (typically the last few months of the year). Medicare open enrollment is October 15 through December 7 yearly and for individual insurance (not through your employer, through Healthcare.gov), open enrollment is November 1 through December 31, though this varies state to state.

Understanding costs is also crucial and those associated with insurance plans usually have to do with two things: 1) your monthly premium and 2) out-of-pocket costs (like co-pays, co-insurance and deductibles). When choosing a health plan, ask yourself which of the following applies more: Would you rather pay more of a set amount each month (premium) and less when you see the doctor (co-pays, co-insurance or deductible)? OR Would you prefer to pay less of a set amount each month and more when you need to see the doctor? Understanding the difference between in and out of network (you’ll pay more out of network), if a health savings account or flexible spending account is for you (these might save you tax dollars), and if you can easily submit an appeal if necessary are also important factors when considering choosing a plan. Get the comprehensive guide to choosing a plan here.

Help with costs

A large chunk of healthcare costs for those with diabetes comes from a need for prescriptions. Through state and nonprofit programs, assistance programs from pharmaceutical companies, and generic alternatives, there are methods to cutting these costs. For assistance with insulin costs, input your information here to receive your insulin access Action Plan. Additional nonprofit patient assistance programs include FamilyWize, Partnership for Prescription Assistance, NeedyMeds, RxAssist, RxHope, RxOutreach.

Denials and appeals

A denial is when your insurance company notifies you that it will not cover the cost of a treatment or medication. While frustrating, it’s important to know that you have the right to appeal the decision. An appeal is an official ask to your insurance company to reconsider its denial. More than 50% of appeals are successful, so it’s an important avenue (and your legal right!) to consider.

There are a few things to be mindful of when filing an appeal. First: know all necessary details (plan and member numbers and DOB) and keep track of dates, times, and who you speak with. Second: be mindful of timing, as there are limits to how long you may make an appeal after receiving a denial. Third: work with your doctor and their staff to get the best results, all necessary paperwork, and a letter of support. Check out a more in-depth explanation of denials and appeals here.

Prior authorizations

prior authorization (PA) is a requirement from your health insurance company that your doctor obtain approval from your plan before it will cover the costs of a specific medicine, medical device or procedure. Check with your insurance company to get the specific protocol for their authorization process, but the main steps in the process are pretty standard. The common five ones are as follows : 1) check your plan’s policy and formulary to see if PAs are required, 2) locate the process for submitting and obtain necessary forms, 3) work with your doctor, 4) ensure the PA is submitted according to guidelines, and 5) the PA will then be approved of denied, but you can appeal if the latter is the case.

There are a few helpful tips for successfully obtaining a prior authorization. It’s important to work closely with your doctor’s office, knowing which individual handles PAs and heeding their advice on how to be successful. Be extremely thorough, making sure the PA form is completely filled out and entirely accurate, and keeping track of dates, times and who you speak to at your insurance company regarding the PA. Being mindful of timing by starting the process earlier rather than later and knowing all key dates is also a way to help ensure success. A robust explanation of PAs can be found here.

Applying for an exception

Not all medications, devices, and services are covered by insurance plans even though they might be necessary. In these cases, patients can choose to make exception requests. Exception requests are written requests to your insurance company to cover a medication, device or service that a doctor has advised as necessary for treatment. Exceptions for diabetes might include those requested for types of insulin, pumps, CGMs or other treatment. When your doctor recommends a new treatment, check your plan details accordingly or call the number of the back of your insurance card to see if it is covered.

To submit an exception request, 1) check your plan’s information or formulary to see if treatments aren’t covered, 2) locate the process to submit requests for your plan, 3) contact your doctor to develop and submit it, 4) ensure you followed all guidelines and make a copy for your records, and 5) the request will then be approved or denied, but you can appeal if the latter is the case. There are a few helpful tips for successfully obtaining an exception request. It’s important to work closely with your doctor’s office, knowing which individual handles these requests and heeding their advice on how to be successful. Being mindful of timing and asking that the request be approved for the full extent of your time as a plan member is a good idea. A more in-depth guide to exception requests can be found here.

Switching treatments

Needing to switch treatments can occur, and it’s important to take the appropriate steps once you and your doctor have determined that this is best for you. Reviewing your policy should be your first course of action to see whether a new treatment is covered. Call your HR department or health insurance company if coverage is unclear. If the new treatment is covered, you should make sure to understand how much it will cost by reviewing your plan’s formulary or calling a representative at your insurance company. If the new treatment is on a different prescription tier, your out-of-pocket costs will increase. Make sure to determine whether this new treatment will require a prior authorization.

If the new treatment isn’t covered, you should determine the pros and cons of staying on your current treatment to see if it’s truly worth switching. A good idea might also be to see if any alternatives are covered. Gauge the difference in cost and know that if the treatment is deemed medically necessary by your doctor, you can request an exception. Get more detailed information on switching treatments here.

Common issues with insulin, CGMs + pumps

When it comes to your health insurance, common issues might arise and it’s important to be aware of any and all of them. Insulin often involves patients seeing tiering issues because certain brands and types of insulin may be covered or may not, impacting out-of-pocket costs. Consulting your plan’s formulary (list of covered medicines) is helpful in this case. Making sure your prescription gives you the amount of insulin you need is also a must, so be sure you and your doctor are aligned. Test strips can also give patients trouble coverage-wise, as some health insurance plans limit the number of test strips you can obtain over a specific period. Check your plan’s formulary and specific policy related to testing supplies to find out necessary details.

Coverage for devices like insulin pumps and CGMs can trouble patients from time to time, as there needs to be alignment with plan criteria and a prior authorization might be required to obtain a pump or CGM. Pump and CGM supplies also vary in cost and coverage depending on your plan. When encountering pump and CGM issues, consulting the company that makes your device may be helpful for navigating insurance difficulties. Get a more in-depth understanding of common insulin, device and supply issues here.

Working with employers

If you have health insurance coverage through your employer, your HR department can be a useful resource. Firstly, they can function as a health insurance specialist when choosing your plan and might be able to help you determine how to get your diabetes-specific needs met by the right plan, and how plans might affect your care or finances. Secondly, they can be a health insurance advocate for future plan decisions. They can offer support as you begin to use services under your coverage, especially if you find your plan isn’t quite working for you. Lastly, they might play the role of a health insurance intermediary if there are unexpected problems. HR can be there when you encounter challenges and might be willing to gather detail as your insurance claim advocate. For a few helpful scenarios in which your HR department might prove helpful, head here.

Medicare

Medicare is a federally run health insurance program for people age 65 and older and people with disabilities. You can visit www.medicare.gov to get more information. Medicare consists of four parts:

  • Part A covers primarily inpatient hospital and skilled nursing facility services.
  • Part B covers primarily physician and outpatient hospital services, as well as equipment like insulin pumps, test strips and some CGMs.
  • Part C is offered by private insurance companies and cover the same benefits as Part A and B, plus many offer drug coverage, similar to Part D
  • Part D, which covers prescription drugs that you typically obtain at a pharmacy and may also cover disposable insulin “patch pumps”

Parts B and D are most relevant to those with diabetes and day-to-day management. Understanding your options for Medicare is important, and the two basic options are to 1) enroll in Original Medicare Parts A and B, or 2) enroll in a Medicare Advantage (MA) plan. The authoritative place for evaluating available options for Medicare coverage is the Medicare Plan Finder.

Things like test strips, CGMs and pumps can all be covered by parts of Medicare, but this varies depending on factors like method of insulin delivery and device choice. For instance, insulin for injections and a disposable patch pump (Omnipod) are covered under Part D, but covered under Part B if used in a tubed pump. Test strips are covered by Medicare Part B. Medicare will cover a CGM if it has been approved for use in diabetes by the FDA. Tubed insulin pumps are also covered under Medicare, and Medicare has announced that Part D plans may choose to cover patch pumps. Medicare does not currently extend to hybrid closed-loop systems. Find a comprehensive explanation of Medicare and how it relates to diabetes here.

Insurance Terms

A claim is a request that you or your doctor submit to your health insurance when you receive care/services. Your deductible is the amount you are required to pay for medical services until your health plan begins to pay. A formulary is a list of prescription medications covered by your insurance plan, and a premium is the amount you pay monthly to keep your insurance plan.

These are just the tip of the iceberg when it comes to health insurance terms and many prove unfamiliar to most people. Having a glossary is helpful for an easier understanding of the overall healthcare system and what is required of you. For a full list of helpful terms, head here.

 

 

The US healthcare system is complex and can be incredibly difficult to navigate. The glossary below is meant to help clarify some of the many elements of navigating healthcare that most affect someone living with diabetes. For further help choosing the best health insurance for you, consult the Health Insurance Guide.


Affordable Care Act (ACA) – The ACA, sometimes referred to as “Obamacare” was the comprehensive health care reform law enacted in 2010. While the reform extended to many facets of US healthcare, the most important provision for those living with Type 1 diabetes was its removal of pre-existing conditions clauses, where health insurance companies were previously allowed to turn down those with diabetes from attaining individual health insurance plans. Also key in the law was the extension of coverage for those aged 25 and under, allowing continued coverage on their parents’ health insurance plans regardless of school enrollment.

Biosimilar insulin – Insulin that is highly similar to and has no clinically meaningful biological differences from an existing FDA-approved biologic insulin. In other words, the generic form of insulin. (Generics refer to the non-brand-name versions of synthetic drugs. Biosimilars refer to the non-brand-name versions of biologic medications, i.e. medicine that is created from living materials, like a vaccine.) A biosimilar insulin may be used to replace an existing insulin taken by a person with diabetes if it meets additional requirements, including producing the same clinical result as the product it is based off of in any given patient. In some cases, biosimilar insulins may be less expensive than other current insulins on the market but we do not yet know what impact they will have on the overall cost of insulin. Because of new FDA regulation pathways, the biosimilar market is changing rapidly. Ask your doctor what may be available to you.

CHIP – Insurance program that provides low-cost health coverage to children in families that earn too much money to qualify for Medicaid but not enough to buy private insurance. In some states, CHIP covers pregnant women. Each state offers CHIP coverage and works closely with its state Medicaid program. >You can apply any time.

COBRA – If you leave a job for any reason, you are able to extend the employer’s health insurance coverage beyond your employment through a federal law, the Consolidated Omnibus Budget Reconciliation Act (COBRA). However, you will pay 100% of the health insurance premiums, including the portion your employer previously covered, plus an administrative fee.

Coinsurance – The percentage of a health care service you pay after you’ve met your deductible, but separate from a copay. For example, your health insurance plan may require a coinsurance payment on certain specialty healthcare costs, like an MRI. In this case, even if you have already hit your annual deductible, you may still be responsible for a 20% coinsurance payment, i.e. 20% of the total billed cost of the MRI, as opposed to a straight copayment fee.

Copay / Copayment – Your copay is the fixed amount you pay for a covered healthcare service or product after you’ve met your deductible. For example, you may have a $25-$50 copay to see your endocrinologist or another specialist, or you may have a $10-60 copay for your insulin every month. If you have not yet met your deductible, you may be responsible for part or all of the cost of a medication (like insulin) or supplies (like insulin pump infusion sets) until you do.

Copay cards – Offered by medication manufacturers, copay cards reduce the out-of-pocket cost you pay at the pharmacy. They exist for most types of insulin. When using a copay card, your health insurance pays for some of the cost, then the drug manufacturer will pay another portion. If you do not have health insurance or your insurance does not cover your prescription, the drug manufacturer may cover more of the cost. Unfortunately, copay cards are typically not available for those insured through Medicaid or Medicare. You can find the copay cards that will work for you by creating your insulin access Action Plan here.

Deductible – In a health insurance plan, the deductible is the amount paid out-of-pocket by the policyholder before insurance coverage kicks in. Plans with higher deductibles typically have lower premiums (your monthly payment for coverage), and vice versa. Most health insurance plans cover preventive services at no cost to the policyholder, bypassing the deductible. For some health insurance plans, costs associated with everything other than preventative services go towards your deductible. Other plans exempt some services from the deductible — usually services that require copayments such as doctor visits. For some health insurance plans, all out-of-pocket costs count toward the deductible, while other plans have a separate deductible just for prescriptions or specialty procedures, like an MRI.

DME (durable medical equipment) – DME is multi-use medical equipment such as walkers, wheelchairs, oxygen tanks, etc. Most health insurance also classifies insulin pump supplies and some continuous glucose monitor (CGM) supplies as DME, even though you’re only using an infusion set and similar items once. This changes what percentage of the cost of the equipment is covered by your health insurance. Some CGM companies have started negotiating with health insurance to get their supplies covered under pharmacy benefits instead, which increases the amount of cost covered by insurance. If you’re facing a high cost for non-medication supplies under your insurance, DME classifications may be the reason.

FDA (Federal Drug Administration) – The FDA, also referred to as the USFDA, is a US federal agency tasked with overseeing a multitude of regulations ranging from food safety to tobacco products to pharmaceutical drugs and more. Part of their responsibility is to ensure the safety of medicines and medical devices, including insulin pumps, insulin, health apps that make health recommendations, etc. When we say a device or medicine is going through FDA approval, it’s referring to this process.

FSA (flexible spending account) – A tax-free savings account arranged through your employer, where a chosen amount is deducted from your paycheck and placed into your FSA, to be used for qualified out-of-pocket medical expenses. You can choose how much you put toward your FSA, up to the limit determined by your employer. The benefit of an FSA is that it is a designated savings account that is not subject to tax, saving you a bit of money in the long term. However, it is important to be precise with your budget planning. Unused funds are restricted – depending on your employer, you can either only roll over $500 from your current year’s FSA to the following year, or you have 2.5 months into the new year to spend the money. You cannot withdraw money from your FSA for other uses, nor can you spend your FSA money on non-medical items. Please note, there are also childcare FSAs and health savings accounts (HSAs), which have different rules of use.

Formulary (i.e. prescription formulary) – A list of prescription drugs covered by your health insurance or prescription drug plan, also called a drug list. Health insurance companies tend to change their covered prescription drugs from year to year based on negotiations with Pharmacy Benefit Managers (PBMs) and drug manufacturers. This is why you may hear that the insulin you use is no longer “covered on the formulary.” Your doctor may be able to provide a Letter of Medical Necessity to override the formulary listing coverage.

Generic insulin – Generic insulins are called biosimilars. Refer to ‘biosimilar insulin’.

Healthcare exchange – Also known as the Health Insurance Marketplace, this is the service that helps people shop for and enroll in health insurance. The US federal government operates HealthCare.gov for most states, but some states run their own marketplaces. If your state has its own Marketplace, you will be directed to it when you enter your ZIP code on HealthCare.gov. You can apply for individual or family coverage by providing income and household information. You can also use HealthCare.gov to see if you qualify to apply for Medicaid or CHIP.

HSA (health savings account) – A tax-free savings account arranged through your employer or through a selected healthcare plan from HealthCare.gov, where a chosen amount is deducted from your paycheck and placed into your HSA, to be used for qualified out-of-pocket medical expenses. HSAs are only available to those who are enrolled in High Deductible Health Plans (HDHPs). You can choose how much you put toward your HSA, up to the federal limit, which is updated every year. The benefit of an HSA is that it is a designated savings account that is not subject to tax, saving you a bit of money in the long term. Different from an FSA, there is no time limit on when you use your funds. You cannot withdraw money from your HSA for other uses, nor can you spend your HSA money on non-medical items.

HDHP (high deductible health plan) – A plan with a higher deductible than a traditional insurance plan, with the minimum limit determined by the IRS. Currently, the IRS defines a HDHP as any health plan with a deductible of at least $1,400 for an individual or $2,800 for a family. The monthly premium is usually lower, but you pay more health care costs yourself before the insurance company starts to pay its share (your deductible). A high deductible plan (HDHP) can be combined with a health savings account (HSA), allowing you to pay for certain medical expenses with money free from federal taxes. There are pros and cons to HDHPs, but important to note is that they require significant financial planning for anyone with maintenance medication requirements, like those for diabetes, asthma, high blood pressure, etc. Because the high deductible must be hit before insurance kicks in on costs, your cost of care will be front-loaded each new year. Some HDHPs have separate prescription drug coverage for those with chronic health needs, helping to minimize the impact of the high deductible at the start of the year.

HMO (health maintenance organization) – A type of health insurance plan that usually limits coverage to care from doctors who work for or contract with the HMO. It generally won’t cover out-of-network care except in an emergency. An HMO may require you to live or work in its service area to be eligible for coverage. HMOs often provide integrated care and focus on prevention and wellness.

Insulin manufacturers – Refers to the companies who manufacture insulin. Currently there are three primary insulin manufacturers that market and distribute insulin in the US, sometimes referred to as “the Big 3”: Eli Lilly, Novo Nordisk, and Sanofi. These three companies create almost 90% of insulin worldwide. Other companies include MannKind, which makes Afrezza inhalable insulin, Mylan, which makes Semglee, as well as multiple manufacturers who market insulin outside of the US.

Insulin rationing – Refers to the practice of taking less insulin than medically required in an effort to reduce the amount of insulin used, typically because of the high cost of insulin.

Letter of medical necessity – If you have been denied insurance coverage of a needed item or medication, your healthcare provider may be able to submit a Letter of Medical Necessity to your health insurance company. In the letter, they will outline why the item or medication they prescribed is medically necessary. This is a legal document based on your healthcare providers professional medical judgement.

Medicaid – A federal insurance program that provides free or low-cost health coverage to some low-income people, families and children, pregnant women, the elderly, and people with disabilities. Many states have expanded their Medicaid programs to cover all people below certain income levels. Whether you qualify for Medicaid coverage depends partly on whether your state has expanded its program. Medicaid benefits, and program names, vary somewhat between states. You can apply anytime on Healthcare.gov. If you qualify, your coverage can begin immediately, any time of year.

Medicare – A federal health insurance program for people 65 and older, certain younger people with disabilities, and people with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant, sometimes called ESRD). Open enrollment for Medicare takes place from October 15 – December 7 each year, with new plans beginning January 1.

Medicare Part C (Medicare Advantage) – A type of Medicare health plan offered by a private company that contracts with Medicare to provide you with all your Part A and Part B benefits. Medicare Advantage Plans include Health Maintenance Organizations, Preferred Provider Organizations, Private Fee-for-Service Plans, Special Needs Plans, and Medicare Medical Savings Account Plans. If you’re enrolled in a Medicare Advantage Plan, most Medicare services are covered through the plan and aren’t paid for under Original Medicare. Most Medicare Advantage Plans offer prescription drug coverage.

Medicare Part D – A program that helps pay for prescription drugs for people with Medicare who join a plan that includes Medicare prescription drug coverage. There are two ways to get Medicare prescription drug coverage: through a Medicare Prescription Drug Plan or a Medicare Advantage Plan that includes drug coverage. These plans are offered by insurance companies and other private companies approved by Medicare. Beginning in 2021, some Medicare Part D plans will offer insulin at $35 per month out of pocket, with no deductible. Those eligible must enroll during Open Enrollment and choose a plan with this coverage.

Medicare prescription drug donut hole – Most plans with Medicare prescription drug coverage (Part D) have a coverage gap (called a “donut hole”). This means that after you and your drug plan have spent a certain amount of money for covered drugs, you have to pay all costs out-of-pocket for your prescriptions up to a yearly limit. Once you have spent up to the yearly limit, your coverage gap ends and your drug plan helps pay for covered drugs again.

Non-medical switching – Refers to the process by which health insurance plans change what medications are covered under their formulary, leading to a switch of what medication you are covered for under your health insurance plan even though a different medication was prescribed by your healthcare provider. If your health insurance plan has tried to switch you to a different medication (for example, you use Humalog insulin but your health insurance switched you to Novolog), you may be able to get your insurance to cover Humalog by providing a Letter of Medical Necessity from your healthcare provider.

Open enrollment – The yearly period, typically in October and November, when you can enroll in a health insurance plan through your employer or through HealthCare.gov. You’re also eligible to enroll anytime you have a qualifying life event, like getting married, having a baby, or losing other health coverage. You can apply and enroll in Medicaid or the Children’s Health Insurance Program (CHIP) any time of year.

Out-of-pocket (i.e. out-of-pocket insurance costs) – Your expenses for medical care that aren’t reimbursed by insurance. Out-of-pocket costs include deductibles, coinsurance, and copayments for covered services plus all costs for services that aren’t covered.

Patient assistance program – If you are having issues affording the cost of your medication, you may qualify for patient assistance programs through drug manufacturers. Input your information here to see if you may qualify.

Prescription plan – Also known as your pharmacy benefit, your prescription plan refers to what is covered by your health insurance through the pharmacy. Drugs and medications, as expected, are covered through your prescription plan. However, some continuous glucose monitor (CGM) supplies are as well. Some health insurance plans operate their own prescription plan, while some contract a separate company to operate your pharmacy benefit coverage.

PBM (pharmacy benefit manager) – PBMs are third-party intermediaries who negotiate prices between pharmaceutical companies and insurance companies. PBMs’ stated goal is to reduce costs from pharmaceuticals for the insurance companies while improving health outcomes for the members of the insurance plans. They participate in the rebate system and take a share of the profits from prescriptions that are sold to members of the insurance plans. This group is often invisible to consumers and can drive up the costs of prescriptions without consumer awareness. You can learn more here.

PPO (preferred provider organization) – A type of health plan that contracts with medical providers, such as hospitals and doctors, to create a network of participating providers. You pay less if you use providers that belong to the plan’s network. You can use doctors, hospitals, and providers outside of the network for an additional cost.

Preauthorization – A decision by your health insurer or plan that a health care service, treatment plan, prescription drug or durable medical equipment is medically necessary. Sometimes called prior authorization, prior approval or precertification. Your health insurance or plan may require preauthorization for certain services before you receive them, except in an emergency. Preauthorization isn’t a promise your health insurance or plan will cover the cost.

Pre-existing condition – A health condition, like asthma, diabetes, or cancer, you had before the date that new health coverage starts. Since the Affordable Care Act in 2010, insurance companies can’t refuse to cover treatment for your pre-existing condition or charge you more.

Premium (i.e. insurance premium) – The premium is the monthly cost paid to the health insurance provider, and does not count towards your deductible. Plans with higher deductibles typically have lower premiums, and vice versa.

Price cap laws – A recent string of proposed laws across the US, price cap laws refer to the concept of creating a price cap – a maximum amount a person can spend out of pocket – for a monthly supply of insulin. The intention is to create reliable, consistent pricing for insulin, usually aiming at around $100 a month maximum. However, price cap laws are restricted in that they’re being proposed state to state, and usually only apply to people who have health insurance. Some states are proposing price cap laws regardless of insurance coverage, capping out of pocket expenses for anyone needing insulin. You can learn more here.

Rebate – A price concession made by a drug manufacturer to a health insurance plan or a PBM (pharmacy benefit manager), in order to be listed on the health insurance plan formulary. Those in favor or the rebate system argue that it provides lower costs for those looking to get a medication through their health insurance plan. However, the rebate system seems to have significantly driven up out of pocket costs for patients, while restricting access to the medications prescribed by their doctors. Part of the insulin pricing debate in the US is heavily focused on how and why the rebate system exists, and the impact it has on cost. You can learn more here.