Pumping Without A Warranty

My Tandem t:slim pump’s four-year warranty expires very soon (my pump was billed/shipped out to me on August 31, 2012….I was one of the very first people in the world to have a Tandem pump, as I was told this was the FIRST day they were ever shipped to customers)…and now I’m in a bit of a pickle. I don’t like the idea of using a pump out of warranty, because if it breaks/malfunctions you are just SOL.

I have several roadblocks in my way to a new pump: first and foremost my insurance, secondly preauthorization, third…cost.

Insurance: My insurance plan is administered by UMR…which is a subsidiary of UnitedHealthCare. In fact, most suppliers and medical facilities just code my insurance as UHC. Unless you’ve been living under a rock the past few months you know that UHC and Medtronic are enacting an exclusivity agreement as of 7/1/2016 in which UHC is only covering Medtronic pumps (note: they have stated that in SOME cases they will cover other pumps, but the out of pocket cost will be higher for the patient, and this will be in special cases only). I am not a fan of Medtronic pumps and I DO NOT want to go back to one. If faced with the choice to use one or use injections, I’d choose injections.

Preauthorization: My insurance policy requires that I obtain preauthorization from them before a pump will be allowed to be billed. I have talked to the woman who is on the receiving end of those decisions (she then places the orders and bills insurance, for my one and only in-network provider (owned by the company for which I work)) and she has told me quite honestly that a patient already on a pump cannot get another one unless the one they are on is not functioning – even if the warranty was expired for years.

Cost: Even if I could somehow manage to get preauthorization for a new pump…even if I could somehow manage to get that pump approved as a new t:slim pump and NOT a Medtronic…the out of pocket cost to me would be about $1200-$1400 (and considering that UHC has said other pumps, if approved, will likely NOT be covered at the same benefit level, I’d likely be looking at a cost much higher than that..that is the cost only if it’s approved at an in-network price, but my guess is my insurance would say ‘ok, you got the authorization to get it, at an out of network pricing…which means my cost would be more than twice that quoted above (in network I pay 20%, out of network I pay 45%…). I’m already spending an average of $300-$330 a month on the cost of insulin, test strips, Dexcom sensors, Dexcom transmitters (one every three months), infusion sets, and cartridges. This doesn’t include the cost of the other things I occasionally buy too (alcohol wipes, Opsite Flexifix tape, SkinTac, Uni-Solve wipes, syringes to have as a backup, lancets, a new Dexcom receiver (and I use these out of warranty for at least a few months too, which also makes me nervous – I don’t have an iPhone as a ‘backup’ receiver…) Then I also have an annual out of pocket cost of around $750 for visits with the endocrinologist, CDE, retina specialist, labwork…. And this year I broke my arm – which resulted in an ER visit and two follow-ups with an orthopedist – which was an additional $700 in cost to me that I was not expecting. My husband and I recently moved and my cost for gas to drive to and from work went from about $30 a month to $130 a month. I got a newer better car and that price is now reduced to probably about $110 a month…but I also now have a car payment of just shy of $140 a month. I just paid $200 for two dental fillings…I could go on and on and on! In short – it’s not fiscally responsible. I have the savings, but I shouldn’t use such a huge chunk of it on a new pump.

So in short – I guess I’m using my pump out of warranty, for however long I can. For any of my readers using a pump out of warranty, or who have done so in the past – how long have you been/were you out-of-warranty? If you used an out-of-warranty pump and it finally malfunctioned, how long after the warranty expired did it happen? What did you do at that point – get a new pump (finally) or go back to injections long-term?

If you haven’t used a pump out-of-warranty, what are your thoughts on it? Would you do it, or would it make you really nervous? Would you even care?

I’d love to hear your thoughts!

 

EDIT TO ADD: I just reread the information about the exclusivity agreement between Medtronic and UHC. Apparently UHC is only covering supplies on other pumps their customers have as long as they are in-warranty. Once the warranty is expired if you want a pump OR supplies you have to switch to a Medtronic pump. Lovely. I better place an order next week – that will at least get me three more boxes of cartridges and three more boxes of infusion sets until I can figure something else out!

JDRF TypeOneNation Summit 2016 and a Blast From the Past

Yesterday my husband and I attended the Southeast WI JDRF TypeOneNation Summit 2016 event. I went last year but wasn’t sure we’d go this year, since we moved (we bought a house!) and are further away from the event site. However, I got wind of the fact that Gary Scheiner, CDE would be the Keynote Speaker and would be leading one of the breakout sessions. I’m a big fan of Gary’s books (primarily, ‘Think Like a Pancreas’) and so knowing that he’d be speaking was the deciding factor for me!

The event itself was run just like the year before – a ‘vendor fair’ with tables set up and manned by reps from Medtronic, Animas, Tandem Diabetes, Novo Nordisk, Lilly, JDRF, Insulet, etc. The vendor fair was followed by the keynote speech, a breakout session, lunch, another breakout session, and an annual update on the research JDRF has been involved in funding.

I think the most refreshing part is just being surrounded by others who ‘get it’ and not getting strange looks or stares if you check your blood sugar at the table, give a bolus, if your CGM alerts, etc. This year I even had to change my infusion set in the bathroom and it didn’t faze anyone. (I had a set in my thigh that was leaking insulin. I was already going high by that point and I didn’t know how much of my lunch bolus had gone in. I have spare infusion sets in my car, but we had taken my husband’s car to the event and I didn’t have a set with me. The lovely Tandem rep gave me the last sample Inset/T:90 set she had. I changed it in the bathroom at the sink. No one batted an eye at me, standing there with my belly showing, shoving a  needle into myself. It was refreshing for it to be so NORMAL amongst the other women and girls in the bathroom.)  That’s a very powerful feeling.

The keynote speech and the breakout session with Gary Scheiner were informative, but also interesting in that they took us back 30 years in terms of diabetes management. Gary discussed how diabetes management looked 30 years ago and laid out all the many changes that have occurred over time. It was kind of fun to hear someone else poke fun at what we had to work with back when I was diagnosed. Granted, I was not diagnosed 30 years ago – I am only coming up on 24 years with T1D…but still….

I had to deal with a giant meter that took a lot of blood (about 10 microliters, versus current meters that take 0.3 to 0.5 microliters) and gave a result in 45 seconds (meters now give results in 4-6 seconds):

lifescan-one-touch-ii-blood-glucose-monitoring-kit-162

I had this meter! And yes, mine came with a cassette tape of instructions. My parents listened to the darned thing several times.

I also got to deal with exchange diet (carb counting was not something I did until I was about 13 years old):

exchange

I hated the ‘exchanges’. I never really learned how to use this system – my dad figured it all out for me. I used to know how many Teddy Grahams were a starch exchange, though (those were my favorite food when I was first diagnosed).

I also was reminded yesterday of the SUPER (annoyingly slow) insulins we had back then.

insulin

I was put on Regular and Lente at diagnosis, which I used for several years until I was put on Regular and Ultralente. It wasn’t until I began carb-counting that I was switched off Regular and put on Humalog, and then quickly switched to Novolog. I don’t believe I began using Lantus until several years after that.

Ah..the good old days?

It did make me think about how much I appreciate what we have today!

Pre-bolusing

Pre-bolusing.

Most of us know what that means (bolusing for a meal or snack 10-20 minutes before you begin eating) and why it should happen (to give the insulin a chance to start working, so that the insulin action more appropriately matches the timing of digestion), but few of us are really truly doing it as often as we should. It’s just not convenient so much of the time – we don’t always plan our lives around exactly what time we will eat. And in some cases, like at a restaurant, it can seem next to impossible to safely do.

My dad always pre-bolused me as a kid – I was on Regular insulin then, though, and that insulin could take 30-60 minutes to even START working.  More ‘modern’ insulins take around 10-15 minutes to begin working. I’ve become lazy about pre-bolusing in the past few years, I’ll admit it. Lazy to the point where I’ll finish a big meal before I even CONSIDER bolusing. By which point my blood sugar is already going up, sometimes rapidly.

As I believe I’ve mentioned before, I had to switch from my beloved Novolog – per what my insurance company wants – to Humalog. I’m not a fan of Humalog. I’m using a lot more insulin (my I:C ratio went from 1:10 to 1:7.3 (yes, with a t:slim you can be THAT specific), my correction factor went from 1:40 to 1:30 during most of the day and down to 1:25 during the mid-day, and my basals went from mostly being 1.2 units per hour up to between 1.5 and 1.75 units per hour)…and with a lot more insulin use I’ve seen issues with my weight (again) going up. I also have noticed that Humalog takes longer to start working and has a longer ‘tail’ or action time than Novolog did.

A few weeks ago I began downloading my D-devices to Diasend – which I’ll admit I’d been very lax in doing at all. I did not like what I saw at all. I was giving way too much insulin chasing highs after meals and my blood sugar average was not where I want it to be.

I started making changes and the biggest one I’ve started implementing in the past week is pre-bolusing. I can’t always pre-bolus (in the morning I need to get up and eat right away, because I don’t have 15 minutes to sit around and wait for my insulin to start working) but when I can pre-bolus, I am.

Look at my results/the change I’ve made, in just one week:

graphs

stats

Just by pre-bolusing I’m spending 14% more time in range (between 70 and 180 mg/dl) and because I’m not chasing highs after the fact (highs can cause insulin resistance, and then you need MORE insulin to get you back to your target than you may have needed if you’d just bolused appropriately to start with) I’ve decreased my average insulin usage per day by about 15%.

And bonus: I lost just shy of 1 lb this week, without trying at all (I know, big deal…haha).

How many of you, my readers, regularly pre-bolus for meals? Does it make a noticeable difference for you, the way it does for me? Also, for anyone out there with gastroparesis, how do you handle the entire idea of pre-bolusing during a flare-up? I have flare-ups pretty irregularly, but when I do, I cannot imagine pre-bolusing would at all be safe – my food can takeover 16 hours to digest (I won’t even tell you how I know this). I’m still unsure how to handle bolusing during a gastroparesis flare-up, despite being diagnosed over a year ago.

 

Seeing A New Endo

Most people know what it’s like to start seeing a new doctor – there is always that question of ‘will I like my new doctor?’ present in the back of your mind. When you have a chronic condition like diabetes, that is further exaggerated because in most cases doctors are important pieces of the overall equation.

I am comfortable making changes to my insulin dosing on my own, and I don’t need my doctor for that, nor do I need my doctor to tell me whether I am doing well or not – I can tell this on my own. However, I do rely on my doctor for my prescriptions and my access to the prescription devices that I use – and I don’t want a doctor who tells me ‘no’ when/if I want to try something new. I want to feel supported, while also feeling independent.

Those characteristics aren’t always so easy to find. So I was a bit apprehensive this morning as I set out to see my new endo – which I should have done MONTHS ago (but it kept getting put off, appointments got changed, etc).

I am thrilled to report that my fears were completely unfounded. My new endo is wonderful. She asked me about my history with diabetes, my history with my various pumps, how my ability to feel hypoglycemic events is (pretty nonexistant), recorded my pump settings, discussed my A1c (6.2%) with me, checked my feet for sensation, decided I didn’t need changes to my insulin rates at this time…She honestly spent at least 30 minutes with me, which was unexpected (how many doctors spend half an hour with one patient?!…very few) but welcome.

She set me up to see my favorite nurse/CDE in 4 months to do another A1c, my bloodwork, and to discuss pump options – since I will be due for a new pump in late August/early September when the warranty on my t:slim expires.

Whether I stay with t:slim or move to something else will be a post for the future…

When Suggestions Go Wrong

I am part of several ‘Pay it Forward’ groups on Facebook. This morning in one of them someone asked very nicely for Verio IQ strips for a friend’s daughter, who is a toddler. I don’t use that meter anymore, because it’s hella expensive, so I have no strips to even offer. However, in the attempt to be helpful I did point out that there are several meters out there that have strips that are MUCH MUCH MUCH more affordable.

Specifically I suggested the Relion Prime, TrueResult, and Freestyle Precision Neo. I have all three (in addition the Up&Up Premium meter from Target). I use them all.

I was told that those meters are so highly inaccurate it would be dangerous to suggest those be used for a toddler. I was made to feel like my suggestion was not only unwelcome, it was hazardous.

I’m tired of seeing these strong opinions in the DOC. I’m sick of seeing people who think ‘This didn’t work for me, so it must be bad for everyone!’ mantra that seems to pop up all over the place. I’m tired of seeing the judgmental comments that come from some individuals, whether they intend them to be so or not.

I was not suggesting anything that my experiences would lead me to believe is dangerous.

I use those above mentioned meters. I have an A1c below 6. My A1c hasn’t been above 6.1 in over 5 years. If those meters were SO inaccurate, when I began using them my A1c would have risen, right? I’d have had some lows that were so debilitating I’d need medical emergency help, right? Well, I’ve had neither. The meters work with the same accuracy as the big name-brand super-expensive total-ripoff OneTouch meters.

Many people in the DOC are so scared of ‘generics’ or ‘off brands’ that they’ve become rude and judgmental about the suggestion that others use them as a way of greatly cutting costs. To which I say: get over yourself. If others are using them with great results, you can’t put a blanket statement on those products that they are ‘dangerous’. And if you truly believe they are, take it up with the FDA.

Which reminds me – the ‘generic’ meters have to meet the SAME FDA QUALIFICATIONS as the brand-name meters…..

I guess I’m just frustrated in general with the often-seen mindset that the most expensive product is the best. That is how we are being taken advantage of by the pharmaceutical companies. That’s what they WANT us to think….

Now I think I’m rambling, so I’ll stop.

In a more positive spin: Merry Christmas! I hope your diabetes plays nicely with you today!

Novolog vs Humalog

We’ve all heard our doctors or insurance companies says it.

“Novolog and Humalog are essentially the same. While one may act a little bit faster than the other, or one may have a slightly longer tail than the other…they are essentially the same. No significant differences are seen, clinically.”

Bullshit.

I have used Novolog for years now and I love it. It works well for me. I know when it will start working. I know when it will stop working. I know what it will do to my blood sugar when it’s high.

However, I have an insurance company that insists that Humalog is preferred. I can get my Humalog prescription for a certain copay…which is HALF the amount of the copay if I wanted to continue to obtain Novolog.

Knowing that price difference I (begrudgingly) switched to Humalog. I had quite a nice stockpile of Novolog when I switched my prescription so for several months I was able to continue using Novolog. However, in the past month I’ve had to transition to Humalog.

All hell has broken loose.

I cannot get a firm grip on my basal rates, my ISF, or my I:C ratio. My average blood sugars have been far higher than I was used to on Novolog. The Humalog is unpredictable – one day it will begin working very fast after I bolus, the next day it will seem to take 30 minutes, and the next day it won’t seem to do a damn thing for about 4 hours…by which point I’ve given more insulin (probably a few correction boluses, actually) and then all of a sudden it seems that the insulin I gave 4 hours prior works….along with all the corrections after and I plummet from 400+ to low within an extremely short time-period. Overall it appears to have a longer tail……..usually. But sometimes it seems to have a much much much shorter tail.

I can’t figure it out.

I hate Humalog.

I’m using about 33-40% more Humalog than Novolog and I’m still not seeing results anywhere close to what I was able to obtain with Novolog.

‘Go back to Novolog!’ you say. Yes, simply said…expensively done.

What I really need is a nice long extended weekend to do some basal testing. But it’s the holiday season. I work a full time job and a part time job. One of my jobs is in retail. I don’t have nice long extended weekends.

If you have made the switch from Novolog to Humalog (or vice versa) and have had difficulty, please feel free to share your sage words of advice. If you made the switch easily and with no needs to adjust your doses…well, go away. Your diabetes plays too nicely!

A (Very Quick) Review of the Dexcom G5

This is going to be pretty concise, because there are many features (ex: anything having to do with a phone) that I cannot review. I am an avid Android user and there is no current Android app for use with the G5.

Pros of the G5:

  • Brighter/better colors on the screen: I was never a fan of the black background of the G4 system. I much prefer the brighter white background of the G5 system. Some people have conveyed that they are not fans because they feel it’s too bright, but I feel all the colors work better together/offer better contrast and with my weird vision issues due to my past retinopathy treatments, this is preferable for me.
  • When I am high or low and my Dexcom G5 alerts me it gives me more information RIGHT AWAY, than my G4 did. For example, on both systems my low threshold is set to 70. If I hit 65 on the G4 it would alarm but the screen (before hitting the button) would just tell me that I was below 70 – I couldn’t see what my actual level was until I acknowledged the alert. On the G5 it will actually tell me what my current BG is before I even acknowledge the alert by hitting the button. This isn’t a major thing, but it was noticeable, and I like it.
  • My G5 receiver feels sturdier than my G4 receiver. It feels just a little heavier, but more importantly the buttons all feel more…solid? I don’t know how I want to explain it, exactly, but on the G4 receiver the buttons always seems ‘loose’ and kind of…wobbly. Everything just feels higher quality on the G5. This could just be all in my imagination however – maybe it’s just a difference between ‘old, very well used receiver’ vs. ‘brand new receiver’ and has nothing to do with G4 vs G5.
  • The battery life of the receiver has been better than anticipated. The manual says 3 days of life on a full charge…but I went 3.5 days before I charged, and I still had about 33% remaining when I began charging.

Cons of the G5:

  • No Android app…..that’s literally my only current complaint.