The Diabetes Navigator

Pharmacy benefit resources

You can learn about your pharmacy benefits by reviewing your plan document.

Start with the basics

Selecting a pharmacy

Pharmacy benefits are administered by Alluma™. Alluma works with a vendor called Express Scripts® to provide certain services, such as the national pharmacy network. The amount you pay will depend on the formulary status of the medication and whether you have met your deductible (for HDHP plans).

Formulary: Your plan follows the Alluma Advantage Formulary, which is developed by disease experts.

The Apothecary Pharmacy: The Apothecary Pharmacy is available for Plan members for convenient pick up of prescriptions and supplies. You may fill up to a 90-day supply of most medications at The Apothecary Pharmacy.

Mail Service: Mail service through ESI Home Delivery offers the convenience of medication delivery and is appropriate for most diabetes medications, test strips, lancets, CGM sensors and certain devices.

Alluma pharmacy network: You have access to up to 64,000 pharmacies across the country and may fill up to a 90-day supply of most medications.

Locate a network pharmacy: Use the online pharmacy search tool, available when you sign into your account
at allumaco.com/members.

Savings programs: Check manufacturer websites for savings on brand name medications for medications like insulin, Ozempic®, Mounjaro®, or Baqsimi®. Provide the information you receive from the savings program to the pharmacy before your prescription is filled. Savings programs may significantly reduce the amount that you pay.

What to know when filling prescriptions at an Alluma network pharmacy

Quantity allowed: Prescriptions may be filled for up to a 90-day supply at The Apothecary Pharmacy or a network pharmacy. You can order a refill after 75% of your prescription has been used up.

Coinsurance: Your portion of the cost of prescriptions will vary depending on which plan you have selected. If you have selected a High Deductible Health Plan (HDHP), then coinsurance will generally apply once the deductible has been met.

Treatment of Type 1 or Type 2 diabetes

Insulin

For High Deductible Health Plan (HDHP) members: Preferred insulin products, including Humalog, Lispro, Lantus, and glargine may be filled at The Apothecary Pharmacy for reduced copay prior to your deductible being met. This will result in lower out-of-pocket cost to you. Contact The Apothecary Pharmacy for additional information.

Plan ahead: If you cannot use the preferred insulins, your doctor will need to request prior authorization. Please allow time for your request to be submitted and reviewed.

Other medications used to treat Type 2 diabetes

Generic medications: Medications such as metformin, glipizide, glimepiride, or pioglitazone will be the least expensive. Metformin may be recommended as the first medication to treat Type 2 diabetes or pre-diabetes.

Prior Authorization: Some diabetes medications require prior authorization (PA) for coverage by your plan. Your provider will need to submit a PA request to Alluma. Alluma will generally provide a response within 1-2 business days. If approved, the prescription may be filled by your pharmacy.

Savings programs: Check manufacturer websites for savings on brand name medications like insulin, Ozempic®, Mounjaro®, or Baqsimi®. Provide the information you receive from the savings program to the pharmacy before your prescription is filled. Savings programs may significantly reduce the amount that you pay.

Other benefits of treatment: Some diabetes medications can also be helpful in treating or preventing other conditions, including heart failure, heart disease, and kidney failure. Be sure to let your healthcare provider know about your other medical conditions to help determine which diabetes medicine is right for you.

Managing your diabetes

Blood Glucose Meters

Save money: You may fill up to a 90-day supply on most blood sugar meters and testing supplies.

Preferred glucometers: True Metrix® and Freestyle Lite or Freestyle Freedom Lite® brand glucometers and test strips are covered by the Christ Hospital Plan. The least expensive option will usually be the True Metrix® glucose meter and test strips.

Continuous Glucose Monitoring Systems (CGMs)

If you use insulin to manage your diabetes you may qualify for coverage of a continuous glucose monitoring (CGM) device, such as Dexcom® or FreeStyle Libre®.

Prior Authorization: Coverage of CGM requires prior authorization, so plan ahead if you are already using a CGM device. Your provider will need to submit a PA request to Alluma.

Pharmacy benefit coverage: FreeStyle Libre® and Dexcom® must be filled under the pharmacy benefit.

Medical benefit coverage: Medtronic GuardianTM is covered under the medical benefit. Please contact UMR at the phone number on the back of your member ID card for questions about coverage.

Monitoring blood or urine ketones

If you have Type 1 diabetes your healthcare provider may ask you to check for ketones in your blood or urine when your blood sugar is high, or if you are sick. High levels of ketones can be a symptom of diabetic ketoacidosis, a serious condition. Urine and blood ketone strips are covered under your pharmacy benefit with a prescription.

Glucagon for severe low blood sugar

Glucagon is used to treat severe hypoglycemia (low blood sugar) when symptoms are too severe to take carbohydrates by mouth. This can be life-saving in emergency situations. Glucagon can be administered as a nasal spray or as an injection. Glucagon products, such as Baqsimi® and Gvoke®, are covered under your pharmacy benefit with a prescription. Check manufacturer websites for savings programs.

Insulin pumps

If you have Type 1 or Type 2 diabetes and require insulin, your doctor may prescribe an insulin pump to help manage your blood glucose.

Pharmacy benefit coverage: The OmniPod® and twiist™ insulin pump systems are covered under your pharmacy benefit with a prescription. You may fill up to a 90-day supply.

Medical benefit coverage: Tandem and Medtronic insulin pumps are covered under the plan’s durable medical equipment (DME) benefit. These pumps and supplies are not filled at the pharmacy but can be ordered by your doctor from a DME provider. Please contact UMR at the phone number on the back of your member ID card for questions about coverage.