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A change in insurance has led to a change in insulin.

We've used up our stash of Novolog, and the first cartridge of Humalog in several years went in the pump 3 days before back to school.

Some people say they experience no difference at all between the two insulins. Some think Novolog withstands heat better. Maybe Humalog sticks around in the system longer. Humalog could be more likely to clog infusion sets. We switched to Novolog a few years ago because it was reported to kick in just a little bit faster. Some of the differences are detailed here, on T1D Living.

The key difference to us is that insurance will pay for Humalog now, and it won't pay for Novolog anymore.

There are too many variables here for this switch to serve as a scientific experiment. The change coincided with an already established need to make some pump setting adjustments. It also coincided with back-to-school, and with the hamster wheel which is marching band season. A couple of things do seem obviously different, despite the chaos.

What we've noticed for sure is a greater need to pre-bolus breakfast. That aspect feels familiar to me from our switch from Humalog to Novolog a few years ago. Breakfast, after which my daughter's bg had spiked significantly almost every day since diagnosis, became more manageable with Novolog. The Humalog is a little more sluggish.

I'd also agree that Humalog sticks around a little longer. It's hard to see during the day, but I'm noticing that the Dexcom graph's downward slope continues longer on the last-before-bed bolus, or for any overnight corrections.

Because we're changing basal rates anyway, based both on feedback from our last endo appointment, and on the schedule changes from the start of school, it's hard to tell what other differences there are. It won't be until we finish tweaking that we can see, for example, if the total daily dose went up.

Given my druthers, I'd say Novolog is probably a snappier variety of insulin, and that it would be nice to go back. But in accounting for Humalog's more sluggish nature we're making adjustments that are working.

Humalog and NPH were the first insulins prescribed when my daughter was diagnosed. The glass-half-full part of me will note that Humalog's challenges are minor and manageable compared to the nightmare that was NPH.

Choosing New Health Insurance

We have spent hours this month investigating our health insurance options.

Since my husband began working at his current company 12 years ago we've had the same insurance. Until now, his company contracted with one insurance company, offering 3-4 plan levels each year. When he began employment there, we chose a plan with a lower deductible, lower coinsurance costs and a lower out-of-pocket maximum. And, of course, a higher monthly price. The per paycheck cost and copays went up a few times, but the coverage remained essentially the same. We glanced at open enrollment paperwork every year, but never considered changing.

This year the company rolled out a completely new system, with choices!!! There are now plans available from 3 different insurance companies, so that, including the various levels of coverage, there were a total of 15 options to consider. Fifteen.

The idea is that each contracted insurance company offers 3-4 levels of plans. The levels are equivalent across insurers. so, for example, the 'gold plan' from each insurance company includes a $20 primary care visit copay, 80% coverage for hospitalization, and $8 monthly copays for tier 1 medicines.

Speaking of pharmacy benefits, also new is that those will now be through the health insurer we choose. For several years now, the employer has contracted with Caremark for drug benefits instead of them coming through the health insurer. And the coverage was excellent. Now we have to factor coverage for insulin, test strips, and other family members' medicines into the health insurance choice.

Our initial instinct was to look into the plans from our current insurer. The devil you know is better than the devil you don't, right? There's a plan with coverage similar to what we have now. We double checked some things, like making sure the deductible was about the same and that the coverage for pump supplies seemed equivalent. We knew our physicians probably participated but we double checked the key ones to be sure they were in this particular plan. Things looked good.

Problem was: that particular 'gold' plan costs about $5000 more per year than one offered through a different insurance company. For a few hundred or so per year I might have stuck with my 'devil you know...' philosophy and bit the bullet. For $5000 we were back to the drawing board.

And it looks like we're rolling the dice and trying a new insurance company this year.

Our doctors all participate. We'll pay more for insulin and supplies, but not anywhere near $5000 more. Humalog is the insulin of choice, with our current Novolog not covered on any tier of the formulary.  I'm worried that I'm unfamiliar with the culture and mechanics of this company, diabetes-wise, and that there will be unpleasant surprises. There will be lots of things to try to get covered this year, with an inevitable switch away from Animas supplies and a possible switch in CGM sensors as well.

But on paper it looks reasonable enough to try in order to save thousands of dollars. I'll let you know how it goes...

Our Options Can't Include Going Down With the Ship

Sooner or later we'll be contacted by Medtronic and offered a Minimed 630G to replace our Animas Ping. Under the Medtronic/Animas agreement, this pump will be at no cost to us since our Ping is under warranty until March 2021. Any other option will, even with the other pump companies' enticements for former Animas customers, come with expense.

The other two automated insulin delivery systems on the U.S. market (besides Medtronic) have their draws. They're both working with Dexcom, and we have a high degree of confidence it the Dexcom CGM system we currently use. Tandem's user-friendly touch screen, new technology and small size are appealing. Ominpod is the only waterproof system left on the market, and it has (by definition) remote control bolus programming, which is one of our favorite features of the Animas Ping especially when the pump is under a dress or buried under layers of a marching band uniform.

Tandem and Omnipod have their downsides too.

Our insurance company now has an exclusive contract with Medtronic for tubed pumps. A switch to Tandem could still be possible, as was sticking with Animas, since my daughter is still in the 'pediatric' category, but by 2021 she'll be considered an adult. Not only do I worry about the insurance coverage, the newness of Tandem is a double-edged sword in my book. While I hope they're on strong footing, I worry they're not yet established enough and I would hate to repeat our current scenario with a company going out of business.

OmniPod's relative stability in the market would make me less nervous, and they do contract with our insurer. We'd still have to pay to switch, since our warranty will be Medtronic's until 2021. But all of that's irrelevant since my kid doesn't like the idea of wearing something as big as a pod on her body and so she will not consider Omnipod, no matter what other features it may offer. It's the only option we've ever had real conversations about switching to, and the answer has always been the same. She likes the potential for invisibility a tubed pump offers. She's concerned not just about the obviousness of the pod, but also the awkwardness under clothing, knocking it off walking through doors, and how it would feel to sleep on it, all of which people get used to but which is still no small concern.

Theoretically we could also include multiple daily injections in the list of options. Or rigging up our own system #wearenotwaiting style. These are not, however, part of our family's conversation.

So, while we have at least the illusion of a choice here, I'm not sure it's much more than that. Financially, Medtronic makes sense. In terms of long-term corporate stability, they also seem like our safest bet. Their product feels the most similar to what we're using now. And in terms of leading the charge towards the artificial pancreas? They're in the front of the race so far.

When we ordered our Animas earlier this year, there were rumors the company might not make it. We certainly knew they weren't likely to release the next big technological innovation. But our warranty was up, and there was nothing compelling enough about what was on the market last winter  to convince us to switch to a new system. We stuck with what we knew, knowing that in 2021 we'd likely be jumping ship to join whatever company was closest to an artificial pancreas by then.

We're going to be thrown overboard instead, and for now it looks like our most viable life raft is Medtronic. We'll hold onto our tried and true Animas as long as we can but we can't go down with the ship, so change is coming whether we like it or not.

Animas No Mas

I poured my second cup of coffee this morning and opened Facebook.  There were pictures of a friend's new kittens and links to political commentary. And then this:

As the parent of a person who will, on Saturday, have been infusing insulin via an Animas pump for exactly 13 years, I have layers of concerns which range from the personal to the way this company's closure shapes the marketplace.

Today we'll begin at the beginning and consider the announcement itself. I learned the news on Facebook. Because I follow 'Children With Diabetes.' They posted a link to an undated, legalese-y notice posted on Animas' website.

We, as I mentioned, have been this company's customers for 13 years. Animas has our email, phone numbers and home address. We have not yet been directly notified in any way. Johnson & Johnson is a huge company. Surely they have a communications arm which could have handled this better? Direct mail timed to arrive today? A call or even a robo-call? Even something as simple as emailing the notice currently on their website. Not only does this feel unprofessional it feels a little like a bad teenage break up... Maybe if I tell enough people I'm gonna break up with her somebody'll put it on Instagram and I won't have to tell her.

Animas' notice includes the following cryptic lines for people in our family's particular situation:  If you are on a pump with a warranty that expires on or after September 30, 2019, you or your pump supplier will be contacted by a member of the Medtronic transition team concerning the option to transfer to a Medtronic 630G insulin delivery system at no cost. This sentence left me with more questions than I had to begin with.

Medtronic, it seems, has a better communications team. I found a link on Twitter to a clearer, kinder explanation. There was a nice line acknowledging that the transition will be "tough." There was also a very well laid out timeline chart which reassured me that customer support will continue to be provided for in-warranty Animas pumps through September 2019 and that we'll be contacted that May to discuss switching over.

But, according to the tiny bit of information I've gleaned so far, we'll be required to switch to Medtronic since we got a brand new Animas Ping system in March of this year, with a 4 year warranty.

Not only have we been broken up with terribly inconsiderately, we now have no choice over who to date next...

More on that next time.