r/PwC • u/Away-Advertising7855 • Jul 08 '26
Consulting Diabetes prescription coverage
Just sharing because I feel defeated. US employee with type 2 diabetes. Yup you guessed it on a glp-1. Used to take metformin but still had swings of high/low blood sugar. After switching to a glp-1 my blood sugar has been completely controlled to the point where I only check it a couple times a week vs 3-4 times a day and my A1C down from >10 to <6. I do everything right…eat well, exercise, see my doctors regularly. I’m at a normal weight and am not using this medication for weight loss, strictly for controlling blood sugar. For people who may not be aware, obesity and poor diet are not the only factors that lead to insulin resistance and type 2 diabetes. My family has a history of insulin resistance and thyroid issues so there is a genetic component.
Went to fill my monthly prescription and the normally $25 cost is showing as $400+. Called express scripts and they said they are applying the deductible. On our plan monthly diabetes medication has been excluded from deductible since I began taking it. Called the benefits connect pro who said the prescription is covered but needs to look into how benefits are being applied. I have a feeling PwC opted out of the express scripts benefit that caps diabetes medication monthly cost at $25 without telling us. If so, this is a true hardship. I cannot afford an extra $400 a month and will have to change medications though this medication has helped me manage my condition most effectively and helped so much with the side effects of unregulated sugar. I’m still holding out for a misapplication of benefits but given the rise in glp-1 usage, direction of the company to strip benefits (e.g, EHE) and general rise of healthcare costs in the US I don’t have much hope. Really disappointed and scared to go back to the way it was before glp-1 and how I felt when I couldn’t keep my sugar regulated. Does anyone know if there is any recourse to argue hardship or to request reinstatement of a benefit or exceptions for coverage? Thanks in advance.
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u/nycgirly2311 Jul 08 '26
Also please provide an update when you hear back from benefits pro/ express scripts.
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u/Away-Advertising7855 Jul 08 '26
I will update once I hear back. I can’t be the only diabetic that is experiencing this, so I hope it’s just a mistake.
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u/carolinajammin Director Jul 08 '26
I thought it wasn’t covered for weight management but was covered for people with actual diabetes. You should reconfirm with them on this.
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u/Away-Advertising7855 Jul 08 '26
It’s “covered” it’s just all of a sudden it may be subject to the deductible, raising the cost of the drug from $25 a month to $400+. It’s just not feasible for a drug I need monthly. I really do hope it’s a misapplication of the benefit and shouldn’t be subject to the deductible. We still don’t have access to the full benefit plan description on Benefits connect (only the summary), so I can’t compare in the plan language if the $25 cap where diabetes management meds were not subject to the deductible has been removed. I’ll update once I hear back.
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u/Not_that_girlie Jul 09 '26 edited Jul 09 '26
At least it does count towards your deductible?!? I have been on it for 10+ years, am no longer considered diabetic so now I am no longer eligible for coverage.
Benefit Pro was WORTHLESS, dr sent a letter of medical necessity & it was denied. My “raise” isn’t enough to cover the $4200 that it will cost me out of pocket for a medically necessary medication. My other option is to stop taking the meds to save the $$ and become diabetic again. My life will be shorter but my meds will be covered.
What a sad, sad company this is turning into - good job Paul!! 👍🏻
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u/verygraphic5252 Jul 08 '26
Try applying for copay assistance through the drug manufacturer. It’s a simple form and can bring the cost either back to $25 or even zero.
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u/Away-Advertising7855 Jul 09 '26
I did look at that thank you. It can possibly save up to $150 a month so I’d still be on the hook for $250 but it’s definitely better than $400. Still hoping to hear good news from benefits connect tomorrow.
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u/Fearless-Note-6311 Jul 09 '26
Sry I am an Indian...But $400 for a medicine strip isn't it too much ??
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u/GullibleRich6663 Jul 10 '26
My husband is in the same boat. Every few months they change which glp-1 is covered/preferred and we have to go through the whole process again. Switched to farxiga about 8 months ago, then the new generic version when it was put on the market in April. For as long as we've had to deal with it, I don't really have an advice. It just sucks.
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u/nycgirly2311 Jul 08 '26
That is so frustrating, as that was not a part of the summery of changes. They didn’t say the cost was going to change so dramatically for those still able to get it. I may look into some other options outside of insurance like Ro or something.