Health

Ontario diabetes patient initially rejected Ozempic insurance

A 61-year-old man with diabetes is speaking out after he was initially denied coverage for Ozempic because, he later discovered, it was a clerical error.

Richard Hall, a Brampton resident, was prescribed the drug by his doctor in February, but after filling his prescription and paying out of pocket, he learned that his insurance, Manulife, would not reimburse him.

Only after he argued against it did the insurer discover a clerical error and overturn the decision, potentially saving him $4,500 a year.

“Without that, I was prepared and talked to my financial advisor about whether this is something I should spend the money on in retirement?” Hall told CTV News Toronto. “I was on that path.”

In 2011, Hall was diagnosed with type 2 diabetes. He began exercising for an hour or two every morning, taking a long walk with his dog in the afternoon, and playing golf several times a week during the warmer months to manage his blood sugar levels in addition to taking an escalating array of medications.

Despite his best efforts, Hall’s disease progressed and his doctor prescribed Ozempic in conjunction with metformin, a drug used to control high blood sugar levels.

However, on March 11, he was denied Ozempic insurance coverage in a letter from Manulife.

“We regret to inform you that the information provided does not meet the eligibility criteria,” the letter said. “Please note that we do not contradict the prescriber’s recommendations. However, claims must be decided in accordance with the terms of the policy.”

CTV News Toronto reached out to Manulife and asked why Hall’s coverage was rejected. Within 24 hours, the insurer escalated the case, approving his coverage and stating that information was missing from his doctor’s pre-authorization form.

A photo taken by his son shows Richard Hall, a diabetes patient in Brampton who was initially denied Ozempic insurance. Manulife did not provide details, but a spokesman said the original decision was the result of clerical errors by third parties.

“Once we were made aware of these errors, we were able to obtain the correct information and correct the error immediately,” they said.

Hall said he eventually discovered that the prior authorization form was missing a box that his doctor had to check off to indicate he was taking Ozempic in conjunction with metformin. But it struck Hall as strange that his diabetes and medication history didn’t raise alarm bells, so the insurer asked him if it was a mistake.

Although a resolution was quickly reached and Hall was immediately reimbursed for his first dose of Ozempic, valued at $258, he fears other patients could end up paying out of pocket or not taking the medications that were supposed to be covered.

“How many people accept this and move on?” he wondered aloud.

The federal leaders have already announced this Ozempic is excluded from a national pharmacare programwhich Hall saw as indicative of the fact that there is some hesitancy about this drug, thanks to its ties to a prominent weight loss trendconsidering the plan was only presented on March 1st.

The agreement covers all insulin for type 1 and type 2 diabetes and establishes a fund for supplies such as glucose monitoring devices.

But to Hall, who discounted Ozempic, he said: “That’s like saying in 1955 that we’re not going to cover insulin.”

Within weeks of starting the medication, his blood sugar levels were lower and more consistent than in all his years as a diabetic, he said.

CTV News Toronto was unable to reach Hall’s doctor but spoke with Dr. Harpreet Singh Bajaj, an endocrinologist in Brampton, about how difficult it was for diabetes patients to receive Ozempic.

“I think the insurance companies are concerned – is this patient being prescribed Ozempic for diabetes or for weight loss without diabetes?” Bajaj said. “But this patient clearly had diabetes,” he added of Hall.

A pre-authorization form — the paperwork that was missing a checkbox and led to Hall’s initial denial — must be filled out by a doctor every year.

“If they delay or tie up the doctor and the patient in the pre-approval process … either the doctor will give up or the patient will give up,” Bajaj said, speaking of all insurance companies each having their own version of these paperwork.

He estimates that 30 to 40 percent of the time, when a doctor has no idea why a patient was denied insurance, he will give up because the administrative burden of finding an answer would eat into his time caring for the patient.

“The insurance company basically overrides everyone,” he said.

From Hall’s perspective, the cost-benefit analysis is simple. “If Ozempic gives them better health and a better quality of life in the long run … that will save a lot of money in the long run,” he said.

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