Hello, and welcome to today's webinar, Prior Authorization Hacks. This session is brought to you by the American Diabetes Association's Overcoming Therapeutic Inertia Initiative, supported in part by Sanofi Diabetes and Novartis. Today's webinar presentation showcases how healthcare professionals work through prior authorization barriers for insulin, GOP1 receptor agonists, SGLT2 inhibitors, and technologies such as sensors and pumps. Panelists will highlight payer considerations for Medicare, Medicaid, and commercial health plans. My name is Alex Turchin, and I have the honor of moderating today's program. To share a little bit about myself, I'm an endocrinologist and a clinical investigator at Brigham and Women's Hospital up in Boston. It is my pleasure to be moderating today's session. This presentation is done in collaboration with the American Society of Health System Pharmacists and the American College of Osteopathic Family Physicians. I now have the privilege of introducing today's presenters. Dr. Eden Miller, an osteopathic board certified family practitioner, received her medical degree from Kirksville College in osteopathic medicine in 1997. Returning to the Northwest, she completed her residency in family practice at East Moreland Hospital in Portland, Oregon. Recently completing her certification in obesity management, she's the founder of Diabetes Nation, a nonprofit organization and CEO of Diabetes and Obesity Care, where she practices with her husband, Dr. Kevin Miller in bed. An impassioned speaker, Dr. Miller has given over 1,250 lectures in the field of diabetes to healthcare providers and patients alike. Her adage for care is that she only succeeds as a provider if she turns patients into experts on their own disease. Next, Lucia Novak is a board certified nurse practitioner in both adult health and advanced diabetes management with over 25 years of experience in diabetes mellitus, and is president of Diabesity LLC, located in North Bethesda, Maryland. Her passion for assisting people with diabetes began in 2000 with the establishment of the Diabetes Institute of the Walter Reed National Military Medical Center, located in Bethesda, Maryland. She herself has co-authored and co-authored many published peer-reviewed articles, book chapters, webinars, podcasts, and continuing education presentations. Her nearly 30 years of nursing experience also include active duty service as commissioned officer of the United States Army Corps. Of all of her contributions, she's most proud of providing the highest quality of healthcare to the deserving men and women of the U.S. military. And Kayla Wagner is a clinical ambulatory pharmacist at Theda Care in Appleton, Wisconsin. Kayla graduated from Concordia University, Wisconsin, with a doctorate of pharmacy. She went on to complete a PGY-1 pharmacy residency at Doctors Hospital at Renaissance in McAllen, Texas. Kayla worked as an inpatient pharmacist prior to transitioning to her current position in ambulatory care. Kayla's passion is working one-on-one with patients to create medication regimens that are tailored specifically to each individual. Kayla spends much of her time working with patients who have diabetes and congestive heart failure to achieve clinical goals that are financially feasible. Outside of work, she enjoys standing to her garden and spending time with her husband and son outdoors. Here are the relevant disclosures for today's webinar. By participating in today's webinar, you will be able to identify methods to be successful in obtaining prior authorization for diabetes medication and technology and apply workflow models that can be used by the diabetes care team to receive prior authorization for insulins, GLT2 inhibitors, GOP1 receptor agonists, and diabetes technology for varying types of insurance. With that said, I'll turn it over to you, Dr. Miller. Thanks so much, Alex, for getting us all warmed up. The three of us are just honored to be able to present to you some of the clinical pearls, pharmacy hacks of overcoming some of the therapeutic inertia that really tends to plague all of us in practice. While we are going to be presenting you our own clinical recommendations and some of the things we learned, we're going to stay on label with those medication indications, but we are going to give you a little bit of edge of how to navigate that. Our particular opinions are not necessarily endorsed by the American Diabetes Association, but we're definitely going to stay true to the standards of care and try to illuminate some of the things that we do as practitioners. I'm so glad that you're here today with us. Here's some of the discussion of the key issues. We're going to start top-down. In general, every health plan will have its own particular formulary. I know that's challenging for all of us because they change every year, and it depends, Medicare and Medicaid, and so some of that is very hard to stay current and up-to-date. Fortunately, many of us do have those EHR systems or those ways in order to get that information, and we do pretty much guarantee that in every single class or field or technology in medicine, all of the plans are going to have at least one option. Now, Medicaid with statewide formulary can be easily to access online. You really have to talk to your staff about how to do that workflow, but it will have that particular formulary, but oftentimes, Medicare, we say is kind of a crapshoot, and you know what we mean by that. We don't want to try to be harsh, but it really is very challenging at times. Now, one of the other things we hear about is step therapy, and step therapy is that you have to fail this before you go to that. Mother, may I, can I do this particular thing? Now, one of the things I want to remind our listeners here today is that step therapy, at least in several states, I'm not going to list them, really is not allowed, and what I mean by that is there's been legislation recently that says, hey, listen, we're going to go to the prescriber, go to the clinician, stay with the standards of care, and not require prescribers to go through a particular step. Now, just as a way to document in your charting, the 2023 ADA guidelines for medication initiation, past identification of type 2 diabetes, as well as diet and exercise, does not necessarily have metformin as that first line. We now know, and Lucia will go through later as we look at the different comorbidities, the other accessory things we're trying to do. So remember, you don't have to necessarily fail metformin. However, that failure can often be related to the state, or the payer, and so requiring to document that failure might be a step necessary for you to go on. Another thing, too, is that I like to embed in my notes, that is my documentation, all the things that I've done. I like to ask the individual how long they've had diabetes, what medications they did well before they saw me. I want to make sure that that is documented in the note, and then my staff can then pull that information out and use that to cover my meds or whatever EHR system you do for prior OSC. Make sure, do the best you can with accurate ICD-10 codes. I have a list of the most common ones with diabetes, with those comorbidities, because we know that the comorbidities often can help get things covered, right? If you have diabetes and heart disease or kidney disease, and Lucia will go through that. And finally, this is one of the things that many of you may or may not have taken the time, and I've recently been doing that a little bit more, is involving the patient. I know many of them say, oh, I have to be on hold for 45 minutes. It's like, well, sometimes better you than me. In addition, it's also their involvement and engagement. I've been handing out printed informational sheets for the type of medications and classes I want them to do with questions to ask their payer, because it can be the catalyst at times when a participant, an individual with a disease, as well as those who utilize the insurance, when they are involved in that process, you can sometimes get it authorized. So I'm going to go through the insulin prescribing hacks and authorizations to give you a little bit of clues in what we do in clinical practice. Now, this is my first tool that I want you to be aware of. In addition, we're going to be here at the end to answer lots of questions and answers that you have, but we wanted to make sure that you actually had tools and resources. Why do I put this? I have this printed out at every station in my office. Why? Because many of you are encountering what we call the quantity limits regarding insulin, right? Y'all have had them. I have as well. It's very hard to remember how many MLs is it in a vial? Is it in a pen? How many packs per pen? How many units per pen? And this is a great type of tool that you can use both yourself as well as those who are helping you with authorizations. It has the brand as well as the generic names. It has what kind of device it is, the dosing increments. As you can see, this is a very, very nice tool. And then I laminate it and put it around the office. It saves time, especially in those repeat things that occur. So I wanted to make sure that you guys had this. Now how do you make that Rx go further? So one of the things we do in terms of hacks, and I know y'all are going to say, well, some pills can't be broken in half, but some pills, you know, are you, you know, stretching the truth by prescribing a higher amount on a particular script? And I would say, we want to make sure that those pills can be broken in half. We don't want to do any extended releases, but for those medications that you do prescribe for diabetes that can be cut in half, it allows you flexibility for two reasons. It allows you, if you're starting on a particular dose and you're going to increase it or decrease it at times, this allows for that in the script. In addition, when you are looking at the ability for individuals who have cost barriers related to copay, it might be one of the ways that you can enhance that. In addition, I tend to prescribe my insulin as the maximum units daily. I don't just put, well, they use 10 units daily. I take it the maximum amount, whether they were ill or whether they have other ongoing titration also with insulin delivery devices, make sure you're doing enough for the reservoir size as well as the tubing. And so keep that in your head. And so when I write that prescription, I put it on there up to so many units per day divided into three meals. This is what's challenging. If you use a range, oftentimes you'll get it kicked back. So I do an up to particular type of verbiage. In addition, if you are placing it in a pump, it depends later, I'll talk to you about whether you should put the word pump or not. It can sometimes trip us up a bit. In addition, consider using available concentrations of insulin if you require a higher dose, or if you have a cartridge that seems to run out and you do a lot of changing, this may require you to do a pause of workflow, especially if you're going to be doing dose adjustments in pumps, that's something you'll have to reprogram. But fortunately, if you're doing injectables with pens, it will do the calculations for you based on units. And then finally, many of us are aware that there are dosing increments in certain GLP-1s and multi-dose. It can be a way to facilitate dose adjustment. We call it clicks. It's just one other tool. Every single GLP-1 has that. Some are auto-injectors that you're not able to mitigate that particular clicks with that. And so when you look at the acquiring of the medication based on commercial, many of you know that there are copay assistance programs. Have these as handouts. Have your staff aware of it. Do that workflow so you can just hand it to somebody, empower them to go online for patient assistance programs through the manufacturer for commercial. Many of us do this because we hand out those coupons. In addition, we also have vouchers. Vouchers are different. They actually allow for a free trial of a particular agent, not a copay offset. Many of you do not carry samples, but vouchers is something you as licensed practitioners can actually obtain. Now cash pay is a little unique. We want individuals to shop around. We look online. There are many different discount options. Many of you are familiar with them. Those type of coupons that can be utilized and understand what's unique about the United States is you can have one pharmacy on one side of the street and one pharmacy on the other that have different types of pricing. There are occasional patient assistance programs for those who are cash pay related to income and you can navigate that as well. Now Medicare to me, I think is the most challenging thing. It feels like everybody is in the dark. There are different informational guides that you can get through the different pharmaceutical companies that have an explanation on Medicare. You can also go on the Centers for Medicare and Medicaid and print off navigational information for people because this is challenging. We have that $400 out of pocket deductible annually. We have that 80-20. Then we have the 25-75 or in some cases the 40%, 60% where they need to navigate. Then they go into the donut hole and then they go through the donut hole. I often tell individuals if you have Medicare, it takes $3,700 to get to and through the donut hole in terms of expenditures for the individuals, not total drug costs submitted to pharmacy but expenditures for the individuals. Being aware of this, they can help plan accordingly and understand that there are so many related to that. They go to the pharmacy and each time it's a different type of process. We have extra help for those that are low income, 65 and above. There are copay assistance programs for Medicare. They're not the copay cards. Occasionally vouchers work for them but they need to be applied for. Many of you know the new federal mandate for $35 insulin through Part D. Here's my hack for you. If you utilize insulin through Part D, D as in drug, not B as in boy, which is durable medical equipment, avoid using the word pump in the script even if they are obtaining that insulin through the Part D. If you put pump, it will kick it into Part B and some pharmacies don't process through Part B and it can be challenging. If you are prescribing the insulin through Part B and you want to put it through Part B in a participating pharmacy or DME company, make sure you put it that it says pump. It can be challenging though. As many of you know, it's harder and harder to acquire Part B coverage and it varies by region and by state. Then in Medicaid, there's good and bad with it. The good is you get what you get. In other words, whatever they cover is what you get and it's rare that you're able to appeal and only in special situations can you appeal that, whether it's a complete adverse reaction or a particular type of need that an individual has. I'm going to turn it over to Lucia and she is going to cover GLP-1s and SGLT-2 inhibitors. All right. Thank you, Eden, for bringing us into the start of how to overcome the issues with these prior authorizations. In my section, what I'm going to try to help you to understand is that this problem probably is not going away and in fact, it's getting worse. I was just reading an article where they looked at healthcare providers between February and March of 2021 and they estimated that over 75, almost $76,000 per prescriber were wasted every year with our time involved in trying to get these. I read somewhere else that there should be one full-time employee dedicated just to do prior authorizations for every 2.7 prescribers. Who does this? Nobody. Nobody can afford this, at least I can't. Less than 30% of prescribers even have staff specifically for doing prior authorizations. Here's a polling question for you. Which do you believe will have the greatest influence to strengthen an ability to have a GLP-1 receptor agonist or an SGLT2 inhibitor approved for your patient? Is it A, having a peer-to-peer call? Is it 2, having any ICD code that reflects that the patient has type 2 diabetes? Is it 3, documentation that supports your rationale? Or is it 4, speaking directly with the pharmacist dispensing the medication? So what I'm seeing coming in is the majority of you are answering 3, documentation that supports your rationale, followed by number 2, an ICD code reflecting that the patient has type 2 diabetes. And I will tell you that 3 is the correct answer. And number 2 is not the correct answer, only because you don't want any ICD-10 code. You really want these codes to be specific for what your patients are experiencing. So yeah, we need to make our case from the very beginning. You want your medical progress notes to reflect what your decision making is and why from the very beginning. Because sometimes insurance companies don't want just the most recent progress note. They might ask for several of them. And so you want to show from the very beginning what you believe this patient needs based on what's going on. So they have a history of type 2 diabetes. Is it complicated by established cardiovascular disease? Or do they have a number of risk factors that raises the risk of when and not if they're going to have an event? Do they have diabetic kidney disease and or CKD? Give us the stage. And you also need a urine albumin creatinine ratio to fully stage chronic kidney disease. So please, if you're not getting urine albumin creatinine ratios or UACRs, please start including that in the screens that you do for your patients. And then of course, CHF. List what microvascular complications they might have, because that's going to be key in your supporting as to why they really can't be on a medication that maybe contributes to hypoglycemia. Because that hypoglycemia in this particular patient could result in significant harm and or even death. What are their current medications? What is their current A1C? What adverse events have they had? And what are the barriers to the effective use of the medications that you're trying to prescribe or you're trying to use in place of what the formulary is stating you need to use? And this is so important, document, document, document what previous medications they were on. Some patients might not be able to recall the name. If they had diabetes for 30 years and they say that they were on some pills, you can pretty much guarantee it was a sulfonylurea and it was probably at least metformin. So write those down and write down what the problem was. Why did they have those medications discontinued? Again, this is to support your information because one of the most common questions is, was the patient ever on metformin? And you have it in your note that, yeah, they were and they didn't tolerate it or whatever else. And then what are your goals for this patient? What is their A1C target? What is their time and range if you're using CGM? Are they at risk for a major adverse cardiovascular event or MACE? Do they have renal complications, low blood sugar issues? Have that documented. And to support you, we have the ADA. And actually the ADA is not the only one that is actually making these very strong recommendations to the point that not following these recommendations, us as healthcare providers could be held negligent if we are not prescribing medications based on risk of what the patient could potentially experience or what they have already experienced and what they may have in their future. And so the American College of Cardiologists also makes these recommendations. The American Heart Association makes these recommendations. More and more of them are coming into line saying, hey, if these patients have this risk, they need to be on these specific drugs, these drugs that have the FDA indication. So it's not any SGLP-2 inhibitor. It's not any GLP-1 receptor agonist. There are specific ones. And so you can document, this is what the expert guidelines are recommending. I, as a healthcare professional in my medical opinions, believe that my patient will benefit from this because of the things that you already mentioned. And that if the insurance chooses not to authorize payment for this medication, they assume liability for not reducing the risk for the events that the patient is indeed at risk for. We can include that in our notes. It's not a lie, it's true. And sometimes it's enough to make the insurance company say, oh, let me address that. So IDC-10 codes matter. And where I see a lot of prior authorizations getting kicked back is people will incorrectly use the ICD-10 code that says the patient has type 2 diabetes and no complications. I guarantee you, your patients have at least one microvascular complication, and God knows it's a buy one, get three free disease. They probably have other comorbids that increase the risk of macrovascular complications. So make sure you're using the ICD codes that are as specific as possible. Your patients who are on insulin should have the Z code, Z79.4, but that is specific for type 2. It's not something that you would include in your documentation for your type 1 patients. So what are the ADA guidelines and the FDA indications? Again, referring to the slide that I just showed you that actually lists what those recommendations are and which ones come with those FDA indications would be semaglutide, injectable, dulaglutide, and loraglutide. The other ones, we haven't gotten all the data yet on the dual. So the terzepatide doesn't have that yet, but that data's coming. The oral semaglutide doesn't have that indication yet, but hopefully will be coming. So these are the diagnoses that you would use if your patient has established cardiovascular disease. It's the E11.59, which states type 2 with circulatory complications. And then you're gonna need to specify what those complications are. You are building your case. So yeah, you may be turning in your note with, I don't know, 10 ICD-10 codes. So choose wisely, pick the one that matches your patients the most. Heart failure. We're looking at that because we really want to be using our SGLT2 inhibitors. Remember, I just mentioned that it's not a class effect for some of these. So you're really wanting to push the drug that meets those FDA indications. And so the issue, again, is using that E11.59 circulatory complications. And then if you happen to know which heart failure, is it preserved or is it reduced as far as ejection fraction? And then using those I50 codes as it applies, if they have chronic kidney disease, your major code will be E11.22. And you're going to need to add the N18 code to determine or to specify what type of chronic kidney disease they have. And then the nephropathy, again, putting in your code for the microalbuminuria or if their albuminuria is above 300. Why? Because a lot of these insurances are following to the T, what the FDA indication is for each specified medication. And so you want to make sure that you are, again, crossing your T's and dotting your I's. The patient has to be involved. Eden already mentioned why can be overwhelmed with co-pays. So even if it's just a $5 co-pay, again, buy one, get three free, if not more diseases associated with diabetes, lots of appointments, many specialists, lots of medications, those little co-pays can add up. But if they're involved in the process, maybe they say, well, I checked with my insurance. It's cheaper if I get it through mail order, We can get them brought into the whole equation and they can be their own advocates, which is really, really important. And then I tell my patients, when you get to the pharmacy, if you have any problems getting the drug that we have ordered, please do not rely on the pharmacist to say that they're going to contact me, even though they said they would, because oftentimes I don't know where that call is going. It doesn't always come to us. Maybe it does, and it's three days before that message gets cleared, or perhaps the pharmacist is really busy and that call never came through. So I put it on the patient to let me know immediately if they are going to be walking out of that pharmacy without medication in hand. So let's look at a case study, and her name is Sally. She's 72. She has type two diabetes. She lives independently and alone, but she's very active. She's got a history of established cardiovascular disease. She has a remote history of an MI several years ago. She also does have diabetic kidney disease, hypertension, dyslipidemia, and obesity. What are her complications? This is my note. And this I want to make available to you so you have your own roadmap to kind of copy if you need to. What are the complications? List them all out. And I always include whether or not they have a history of hypoglycemia as a complication of their diabetes. What are their current meds? Okay, so because this is a CME, I couldn't list trade names. So I list out their medications by name in their record, what they're doing. And I said, she's on Metformin 1000, she's doing okay, but she ends up having diarrhea on higher doses. And I don't know what her current renal function is. What other meds is she on? We want to make sure that we're covering all those bases of what do the guidelines say need to be in place before I order an SGLT2 inhibitor if it's specifically for chronic kidney disease protection, those kinds of things. And so the ARBs or the ACE inhibitors are gonna be important to be mentioned. What were her previous meds and why did we stop them? Okay, again, very important to have that documented somewhere in the note. So this is her A1C 8.4. However, it's with hypoglycemia, meaning that that A1C is falsely low, that it's probably even higher than that and she's having low sugars. Here's her GFR, it was 60 a year ago, it's come down to 40. And I also showed the change in her UACR. So now I've built my case. What are my concerns? My concerns is that she has established cardiovascular disease, not currently on a medication with MACE benefit. She has decreased renal function, which places her at risk for hypoglycemia with exogenous insulin. The hypoglycemia could cause potentially fatal event in people with established cardiovascular disease and decreased renal function progressing and will require dose adjustments of current meds. And she has an elevated A1C despite hypoglycemia. So now I've listed out all of my concerns with this patient and now I'm gonna say what I need to do. So these are the diagnosis codes for her. Again, we're using the established cardiovascular disease and I put that she has one, our I25.2, which is a previous MI, or you could use I25.9, which is an MI unspecified. She also has chronic kidney disease and she has albuminuria. So I'm specifying that out with an E11.21. I am adding the N18.32 to specify her chronic kidney disease stage 3B. And I'm adding the R80.9 for her microalbuminuria that she's excreting. I'm also going to include in there that she's got hypoglycemia and that she is on insulin. Again, this is that Z79.4 is not used in people with type 1, that is specific for type 2. So now I've built my case and I have the diagnosis codes to support it. So what's my plan? So if I'm looking at that established cardiovascular disease and I said that she's had that MI, I'm putting that in there. She's got a history, previous MI. According to the ADA, the ACC, the AACE, you can throw in whoever else you want to, she should be on a medication that is indicated to reduce the risk of MACE. Preferably a GLP-1, list those out or alternatively an SGLT2 inhibitors, list those out. I am recommending GLP-1 agonists at this time as they are also effective for management of glucose without hypoglycemia and can be used safely in patients with renal or hepatic insufficiency. Not to mention if I can use one that actually reduces her risk for MACE. And I did the same thing when it came to her CKD diabetic kidney disease. I listed out the main code of nephropathy. I included the stage of chronic kidney disease. I included that she has microalbuminuria. And now I'm staying, she's got progressive renal disease as evidenced by an EGFR of 65 a year ago down to 40 just a year later and her albuminuria is elevated. She's had a history of an MI which makes her risk for heart failure quite high. And she developed some issues with edema and shortness of breath when she was on a TZD in the past. So again, justifying, making my case and then putting in there, what do the recommendations of the expert guidelines put out? And what am I recommending and why? So I am recommending SGLT2 inhibitor at this time which will prevent the progression of end stage renal disease, reduce her risk for heart failure regardless of where her EGFR is. And if her EGFR is below 40, it's not going to be enough to address hyperglycemia. That's the ticker with the SGLT2 inhibitors. So I'm still going to need to not only offset the heart failure and the chronic kidney disease risk, I'm going to still need to address her underlying hyperglycemia. And so this may be where you will be able to eventually justify using both a GLP-1 receptor agonist and an SGLT2 inhibitor. And then of course the hypoglycemia. Again, I'm building the case as to why I need specific agents and I'm going to make sure that case is made in all three of those risk factors that I believe she had. Now, let's say the insulin cannot be stopped in Sally that despite adding a GLP-1 and an SGLT2 inhibitor, we can't stop it. I can use that information about her hypoglycemia to support the need for a CGM because the most recent Medicare guidelines which I'm sure Kayla is going to be discussing actually allows us to not have to have the word insulin even in the equation. So that's a nice way to segue to Kayla right now about continuous glucose monitoring and the insulin pumps. Hi, thank you, Lucia. So we're going to talk about how we can get some of these continuous glucose monitors and our insulin pumps covered depending on the coverage that patients have. So again, like the SGLT2s and the GLPs, it varies by which type of insurance. So Medicare CGMs must be sent to durable medical equipment or DME suppliers or pharmacies that process Part B benefits for Medicare. And so there's not very many pharmacies that do process that Part B benefit. So you have to know that in your community. There are a couple of exceptions to this and I feel like this is growing as the years pass but UnitedHealthcare and Network, they will now cover CGMs at retail. They still have that requirement of being on at least once daily insulin, but that makes it super easy to get them for patients and they are free of charge. Medicaid, they only cover their four miliary CGM. So like Eden said previously, they have their CGM that they prefer and that's the one that you can get. Again, preferred pharmacies that can process these and preferred DME suppliers. These vary widely by your state. So you'll have to be familiar with your requirements for your state. Medicaid nationally covers for type 1 diabetes but coverage for type 2 and gestational diabetes varies again by state. For commercial insurance, again, it's gonna vary but note that the deductible and co-pay may be more than actually just paying cash for a CGM for these patients. So who needs a CGM and who's likely to be covered? Patients on basal insulin and particularly multiple daily insulin injections or those using a pump or AID system might be more likely to have coverage. And again, documentation is key for these patients. Patients with comorbid conditions who may struggle more with glycemic control, such as if they have cardiovascular disease, chronic kidney disease, if they have cognitive or dexterity barriers, documenting that and providing that documentation when you submit a prior auth for these agents is always beneficial. Okay, when we talk about the documentation for these to get CGMs, to be eligible for a CGM, we must document their type of diabetes, any diabetes related events. So whether they have hypoglycemia, hyperglycemia or if they were hospitalized due to a diabetes related event. Their insulin regimen, particularly for Medicaid, it's very important to document the adjustments of insulin dosing that's required. So a lot of times it comes back to us saying, hey, what are the patients doing with their sliding scale insulin? They actually want to know the sliding scale for their insulin regimen. And then again, it's always helpful to have more information. So do they have a connected pump? Do they have gestational diabetes? So the more information you can provide, the better. Medicare coverage guidelines. So to be eligible for CGM and related supplies, they must meet all of the following criteria. So they have to have a diagnosis of diabetes. You have to document that the beneficiary or their caregiver has received training in using the CGM that is prescribed. The CGM is always prescribed in accordance with its FDA indications. And then this is where Lucia was commenting. So you can either be either insulin treated, so just once daily insulin, or have a history of problematic hypoglycemia. Again, you need documentation of their hypoglycemia. They don't have to be hospitalized for it, but having that documentation helps them meet the coverage guidelines. And they also have to have had their last provider visit within six months of ordering the CGM. We're gonna take a look at our case study, Peter. So Peter is a 36-year-old male and he has type 1 diabetes and he's covered under Medicaid. And he has been managing his blood sugars with four times daily finger sticks. He is on insulin Glargine and Insulin List Pro. He has most current A1C is 8.2%. So our poll question for Peter, which additional information is needed to provide adequate documentation for Medicaid coverage? And so this is a select all that apply. We need CGM training to the beneficiary. We need specific adjustments of insulin dosing, documentation of any acute related diabetes events, and we need a C-peptide. Very good. Two and three. So we need to make sure that we have our specific adjustments of insulin dosing and make sure that if there are any acute related diabetes events that those are also documented. I'm gonna pass it along to Eden for Insulin Pops. Thanks Kayla so much for that overview of CGM. I know we all love CGM and what it provides that information and it can be challenging, but if you familiarize yourself with the directions of where to send the prescription, give the patient a few questions to ask, you can be successful in obtaining it. So now I'm gonna briefly go over insulin pumps, insulin delivery devices. These are an expanding field. They really are becoming not just a type one individual, but rather those with type two diabetes. And so there are some specific ways of how to obtain them. For Medicaid, again, it varies by state. At least in my state, we do have universal coverage for type one. It is considered the standard of care. We often see multiple types of pumps that are approved. It used to be just one particular pump, but we're now noticing that many of the pumps or different variations are covered. It's only a rarity that will run into particular limited formulary based on type one. Type two diabetes, on the other hand, has a different kind of coverage, whether it's a patch or an external tube pump and gestational diabetes as well. Even though gestational diabetes, individuals can vastly benefit from CGM as well as insulin pump therapy. In my state of Oregon, we do not have that ability to do that, but that's an ongoing conversation that we're having. So one of the things I wanna remind you in the note is document the history, tell a story, tell a narrative. You need to discuss how you have done multiple daily injections. You have had the patient titrate according to either CGM or finger stick data. And that when doing that particular pump, you gotta make sure that you go to the direction of where it's provided either through DME. Some of them have been recently with Medicaid provided by pharmacy, which is awesome because it kind of removes another barrier. This is a great place for the person to call their insurance as well. I know we all wanna do everything for them, but this is challenging at time. And so I often, if I can't obtain that information or I don't know it based on my experience, I say, hey, this is the pump that we want. This is where I want you to call and find out where they prefer it. This is just engaging the patient and doing that. Commercial insurance really is very broad as well. Again, occasionally at our particular plan, but we really see quite a bit of universal of all different brands available for type 1 diabetes. We also see expanded coverage for those with type 2 diabetes. You need to also do the same documentation as above multiple daily injections, whether there's hypo or hyperglycemia, you could talk about variability, which is kind of a CGM term that we use, what we call the ski lifts and the ski jumps or the peaks and valleys. Now with Medicare, it is a little bit more specific. Those with type 1 diabetes also need documentation. And we can see those particular recommendations here. I always just crack up every year. Those individuals over 65 on Medicare who have type 1 diabetes, the Medicare is so optimistic. They think every couple of years that a person with type 1 has been cured. And so what they require us to do is that the individual have a C-peptide level. And so this is very specific because you need to order this lab. The individual needs to go in with a glucose less than 200. And so you have to have that C-peptide and glucose level for type 1 diabetics, usually every two years, and they need to do it in the morning. If the blood sugar is above 200, you need to go back and do that again. In addition, that's a very similar type of recommendation for those with type 2, but we'll review with that. So you can see, this is this history. This is this individual that has either had failure of control. Now, remember, this is an initial approval that there's been comprehensive adjustment, three plus doses, A1C out of control, or hypo or hyperglycemia, as well as those wide variability and fluctuations. Fortunately, a lot of the manufacturers have these checkoff lists, which is nice. So do engage with those manufacturers of pump because they allow us to do those checkoff lists. And those with type 1, like I said, really should be monitoring four times per day or using a CGM. Now, finally, we'll end with those with type 2. So type 2 has a similar type of thing. Many of us are like what insulin delivery devices and technology provide. We really do have to have an individual where their C-peptide is below the threshold in comparison to the blood sugar. I still try to get that blood sugar less than 200. There's a couple of reasons for that. As you know, the blood sugar that goes lower, the C-peptide is lower. So it's a way to kind of get that metric covered because we want that C-peptide less than two with a blood sugar less than 200. You need to submit that as well as all the other recommendations regarding the comorbidities they're having, hypo and hyperglycemia, lack of engagement, lack of control, A1C greater than seven. And then for ongoing approvable for type 1 and type 2, it's usually every couple of years that C-peptide and glucose level. I do see more type 1s requiring to do that on an every few year basis. So this was just a little bit of overview of how to acquire those insulin pumps. And I'm gonna have Kayla take us into the question and answer by going through workflow. So for those not familiar with Cover My Men's, it's a platform that can be used to submit electronic prior authorizations. So there's a way to integrate that into some of the electric health records that has proven for my practice to be very time-saving. So you don't need to enter any patient provider or insurance details. You just enter it based on your prescription that you sent through and all the patient's information's already in the EHR. And kind of like Cover My Men, you get a quick response from the insurance company. I do feel like it's quicker coming through the EHR system. For DME supplies, we also use Parachute Health. So it's another helpful platform for submitting and ordering DME supplies. So CGMs and those insulin pumps. And we're gonna walk through these two tools a little bit more with our case. So now we're gonna talk about Maggie. So Maggie is a 67-year-old female and she has type 2 diabetes, ASCVD, and obesity. And her VMI is listed there. She presents to the clinic for a three-month diabetes follow-up. She's currently on metformin, 1,000 milligrams twice a day, and her insulin glargine. Her last A1C remained elevated at 8.7% and her EGFR is 65. After discussing with Maggie, you determine that you'd like to start her on a GLP-1 and utilize a CGM for glucose monitoring. She has questions whether this medication and device will be covered under her Medicare insurance. You're able to process her prior off through the insurance prior to her leaving the office by utilizing CoverMyMed's integration to your EHR. So this is what it looks like in our electronic health record. So when we order the medication, it comes up below that we can request a PA, and then all the questions come up on the side panel and you're able to just answer those really quickly for the patient. Poll question. For coverage of Maggie's CGM, it must be filled through a DME supplier, retail pharmacy, or either the DME supplier or retail pharmacy. So it depends. I didn't clarify which type of Medicare insurance she had, but typically a DME supplier, unless she has specifically network or UnitedHealthcare insurance for her Part D as in drug benefits, and then she can get that filled at a retail pharmacy because she is on once daily insulin. Next poll question. So you submit CGM coverage for Maggie through Parachute Health, ensuring that you document all of the following for Medicare coverage except. So which one don't you need to document for Medicare coverage? That CGM education was given to her or her caregiver, her most recent A1C, current insulin regimen, and the visit with a provider within the last six months. Okay, it looks like this tripped up a lot of people. So for Medicare, about 44% chose that you don't need CGM education for the beneficiary. So you do, you have to document education to the beneficiary or their caregiver. That's one of the five key components for Medicare. The answer is actually the most recent A1C. So you don't actually have to document, it's not one of the key components for Medicare. And then finally, utilizing Parachute Health. So this is just kind of a walkthrough of Parachute Health. So you can see that on the side, it shows, it just kind of walks you through the necessary documentation steps. So you put in the patient's insurance, you list their diagnosis, and then it's gonna ask you for the prescription and then also face-to-face documentation. So it asks you for the face-to-face date. And if it was more than six months ago, it's gonna give you a big red flag. And then it also walks you through how many daily injections of insulin do they have documented hypoglycemia. It's gonna ask you whether the beneficiary or the caregiver was educated. So you can do all your attestation on there. And then you can also sign the prescription and send it to the DMV supplier. Thank you all the panelists for the outstanding presentations. Now we're moving to our Q&A session. So please feel free to submit your questions through the Q&A button. I'll start the Q&A session off. And the question is to all the panelists. So please feel free each to provide your own answer. I was wondering what your experience, if any, has been with a kind of new approach to pharmacy, the Amazon pharmacy or the Cost Plus pharmacy, and whether you have found that these new developments provide any relief for our patients. You wanna take that one, Lucia? Sure. So a lot of these retail pharmacies that are popping up online, as well as some of the services that are available through GoodRx or Silverscripts and that kind of thing. Well, not Silverscripts. I forget what it's called, Singles or something. I don't know. But they are really good for generically available medications. They oftentimes, they can get their blood pressure, cholesterol, some of their generically available diabetes medications at a cheaper rate than what their deductible or their copay would be if they went through their insurance. The key thing with this though, is to keep in mind that some of our patients have high deductible plans. And when they use these other retail pharmacies, like the ones on Amazon or the Shark Tank guys pharmacy, or even with GoodRx, the money they pay does not go toward lowering their deductible. And so that could be an issue for our patients when we're trying to make sure they are getting to that deductible so that they can start getting the benefit of their insurance kicking in. So that's just something to keep in mind. But it's a great resource for many patients that are truly paying cash. And therefore you need to be creative with how to make their generics very affordable for them. Yeah, Mr. Cuban also just announced last week that a new SGLT2 inhibitor that was FDA approved will be put on their particular plan for, I'm just gonna, about 40 bucks or so, I don't know for sure. But it is not necessarily one that is currently on the ADA standards of care for those reductions. But it is something that you just continue to stay tuned to. And I did see a question in the chat about Parachute. Parachute Cover My Meds, these are free platforms that you do not have to have a subscription to them. Yeah, and it's a platform for pharmacists or anybody on the care team. You can send it to the physician for signature once it's all prepared for them. Yeah, it's great. It's easy. I just got an email earlier today about an electronic signature through Cover My Meds. It's super seamless to do. You just got to create that workflow in your office. Thank you all the panelists. There is a question in the Q&A box. If you can discuss prior authorizations versus CMM. I think they're synonymous with most insurances. So certificate of medical necessity is another way of some insurances saying that they need a prior authorization. I typically will see Certificates of Medical Necessity come in play with durable medical equipment, pumps, that kind of thing. And then the prior authorization is usually for procedures, certain radiologic procedures as well as- Labs, yeah, that kind of thing, yeah. And I see a question about, does Epic go through Cover My Meds? So I'm gonna switch that back through and Cover My Meds does go through Epic. You just have to get that integration into your system. Great, and there's also a question asking to summarize the hacks for GLP-1 approvals. Okay, so if any of you are expecting like something that you could just do and get it approved every time, unfortunately due to the popularity of the GLP-1 receptor agonists and their association with weight loss and therefore the high off-label use of these medications and the costs associated with them, every insurance company is requiring at least a soft prior authorization, meaning you at least have to justify that they indeed have a diagnosis of type 2 diabetes. And so there's no other way around that. And again, making sure that you're building your case, keeping in mind, what are the GLP-1 receptor agonists currently FDA approved for? Reduction of major adverse cardiovascular events, whether it be a history of non-fatal stroke, non-fatal MI or cardiovascular death. So if they have had a history of those things, this can justify why you would wanna use those medications. And according to the ADA, according to ACE, according to ACC, these drugs are listed as first line despite what their baseline A1C might be. So their A1C could be 6-7 and you don't necessarily need to intensify for glucose management, but you do need to, to reduce risk. So again, it's not just about what's going on as far as the glucose is concerned, it's really those other risk factors that we are being held to as healthcare providers to reduce that risk for these events for the patients. And we need the support of the insurance to help us. So documenting that, kind of making it the insurance's responsibility if they choose not to, the reason why the patient may be at risk. There is also a question from an attendee, whether you have a template for appeal letters for GLP-1 agonists and SGLT2 inhibitors. I don't have a template for an appeal. You know, I loved how Lucia summarized it. I love hearing it from another provider too, because it kind of reminds me of those things. The way I do the appeal is I actually state the particular meds that they have tried and failed. Why? Yeah, it's very, very important because many of the appeals are because you haven't documented the step therapy. And so make sure that your appeal is answering the questions of the initial denial. So I don't do a template because it's very individualized. And then I get a little sassy because that's how I am. And I really say in there, you know, I am doing this appeal because I have followed the recommendations that you have required. The patient has had this adverse event. I am using a medication according to the FDA, according to the endorsements by all those institutions. And in your denial of this, you're going to assume the liability. The inertia is not with me. The inertia is not with the patient. This is the ADA standards of care. And then sometimes if you really want to get super spicy and we're not trying to necessarily make enemies, is that that insurance company is going to assume the liability and the denial of the med that's FDA approved and indicated for this particular prevention. And that tends to kind of get the message across. Thank you. And I think we're out of time at this point. So I wanted to thank again, Dr. Miller, Ms. Novak and Ms. Wagner for really great presentations and very illuminating Q&A session. And I also wanted to thank each of the attendees for joining us today. I wanted to remind everyone to be sure to visit therapeuticinertia.diabetes.org for resources and tools to use in your practice. And this concludes our program for today. Thank you very much again for your time.

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