Ontario diabetes patient initially denied Ozempic coverage

A 61-year-old man with diabetes is speaking out after he was initially denied coverage for Ozempic due to what he later learned was a clerical error.

Brampton resident Richard Hall was prescribed the drug by his doctor in February, but after filling his prescription – and paying out of pocket – he learned that his insurance provider, Manulife, wouldn’t reimburse him.

It was only after he pushed back that the insurance provider discovered a clerical error and reversed the decision, potentially saving him $4,500 a year.

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

Hall was diagnosed with Type 2 diabetes in 2011. He started exercising for one to two hours every morning, taking his dog on a long walk in the afternoon and playing golf several times a week in warmer months just to manage his glucose levels, in addition to taking an escalating series of medications.

Despite his best efforts, Hall’s illness progressed and his doctor prescribed Ozempic in conjunction with Metformin, a medication that controls high blood sugar levels.

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

“We regret to advise that the information provided does not meet the eligibility criteria,” the letter stated. “Please note that we are not disagreeing with the recommendations of the prescribing physician. However, claims must be adjudicated in accordance with the policy provisions.”

CTV News Toronto reached out to Manulife and asked why Hall’s coverage was denied. Within 24 hours, the insurance provider escalated the case, approved his coverage and indicated that his doctor’s pre-approval form was missing information.

Richard Hall, a diabetes patient in Brampton who was initially denied Ozempic coverage, is seen in a photograph taken by his son. Manulife did not disclose specifics but a spokesperson explained the initial decision was the result of clerical errors from a third party.

“Once those errors were brought to our attention, we were able to obtain the correct information and address the error immediately,” they said.

Hall said that he eventually found out that a box that his doctor needed to check off to indicate he was taking Ozempic in conjunction with Metformin was missed on the pre-approval form. But it struck Hall as odd that his diabetes and drug history wouldn’t set off alarm bells for the insurance provider to follow up with him to ask if it was a mistake.

While there was swift resolution and Hall was reimbursed right away for his $258 first dose of Ozempic, he worries that other patients could end up paying out of pocket for, or not taking drugs that should be covered.

“How many people accept that and move on?” he wondered out loud.

Already, federal leaders have announced that Ozempic will be excluded from a national pharmacare program, which Hall deemed telling of the fact that there’s a hesitation with this medication, thanks to its ties with a celebrity weight loss craze, considering the plan was only just tabled on March 1.

The deal will cover all insulin for Type 1 and Type 2 diabetes and establish a fund for supplies, such as glucose monitoring devices.

But to Hall, leaving out Ozempic, he said, “It’s like saying in 1955, we’re not going to cover insulin.”

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

CTV News Toronto could not reach Hall’s doctor, but spoke with Dr. Harpreet Singh Bajaj, a community endocrinologist in Brampton, about how challenging it’s been for diabetes patients to obtain Ozempic.

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

A pre-approval form – the paperwork that had a checkbox missing and resulted in Hall’s initial denial – must be filled out by a doctor each year.

“If they delay or bind the doctor and 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, which each have their own version of this paperwork.

He estimates in 30 to 40 per cent of cases, when a doctor has no idea why a patient was denied insurance, they give up because the administrative burden of tracking down an answer would compromise their time caring for patients.

“The insurance company is basically overruling everybody,” he said.

From Hall’s point of view, the cost-benefit analysis is simple. “If Ozempic is going to give them better health in the long run and is going to give them a better quality of life … that’s going to save a whole lot of money down the road,” he said.