Author: drmandyreece1

Juan, a 34 year old male who has Type 1 diabetes and is on an insulin pump, calls me frustrated that he needs prior authorization (PA) for Humalog which did not require a PA last month. As it turns out, the formulary for his prescription medications changed in April. He is also frustrated because the last time he used another rapid acting insulin his blood sugars ran extremely high and very difficult to keep in range.

Frustration Ensues
In this world of ever changing drug formularies and health insurance challenges, keeping track of preferred medications and medications that require PAs is frustrating for everyone! That includes not only the patient, but also the pharmacist, medical office staff and prescriber. The process of prior authorization was initially implemented as cost savings tool. Yet it seems to have gone off rail at some point in the not so distant past.

So what transpires in the PA process?
In the PA process, the prescriber has to obtain approval from the health insurance company for payment coverage of the medication. The simplified overview of PA process is the following
• Prescriber sends prescription electronically to the pharmacy
• Prescription is processed by pharmacy staff and reviewed by the pharmacist and forwarded to the insurance company
• Notification of required PA is transmitted from insurance company to pharmacy
• Pharmacy communicates electronically to prescriber that PA is required
• Prescriber’s staff completes necessary documentation for PA
• Insurance company reviews and sends reply regarding PA

Minimizing the Challenge
So how can the frustration be minimized? Be informed about your formulary (a list of preferred drugs covered by your insurance plan) in terms of what medications are preferred as well as the cost of any deductibles and amount of copays. Compare the list of your current medications with those preferred by the formulary and note if PA is required. Keep in mind most formularies usually change at least once a year. Ask any formulary related questions to the human resources or benefits department at your employer. Formulary information may also be obtained at the website for your insurance plan.

Resolution
As it turns out, Juan’s provider and I worked together to get a PA submitted. It took about 72 hours for consent and now having the green light for the Humalog PA, I phoned the pharmacist to share the great news. Juan picked up his Humalog refill later that afternoon. A hurdle has been overcome for a person living with diabetes.

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#diabetes #PA #medications #afford #informed

Sandy

Sandy who has Type 2 diabetes goes to her local pharmacy to pick up her prescription for Trulicity®. Upon arriving at the pharmacy, it is explained to her by her pharmacist that her insurance company will not cover Trulicity® without her first “failing” on metformin, sulfonylurea (i.e. glipizide) and DPP-IV inhibitor (i.e. Januvia®). Sandy frantically phones me, her diabetes educator, in sheer frustration. After explaining to her why this has happened, I assure her that we will work through this so she can get the medication she needs approved by her insurance.

What is Step Therapy?

Step therapy is designed as a tool utilized by health insurance plans to contain costs through requiring patients to “try and fail” less expensive medications before receiving the most appropriate medication. Keep in mind these are medications that have been selected by the patient’s healthcare provider! Unfortunately, in reality very little oversight of step therapy exists. There is a lack of evidence showing “fail first” policies are effective or take into consideration adverse effects of insurance company’s preferred medications. Some of the common chronic disease states that are targeted for step therapy are diabetes, cancer, hypertension, HIV/AIDs, pain, rheumatoid arthritis and hepatitis C. The common challenges with step therapy is that the appeal process is lengthy, protocol guidelines are inconsistent, guidelines are not always based on the most current clinical and scientific data, and the inconsistent appeals process lacks appropriate healthcare professional leverage.

Missed Opportunities in Georgia

Numerous states have recently passed legislation that is designed to “reign in” step therapy. In 2018, the Georgia legislature – (my home state) during their annual session, introduced a bill sponsored by Representative Sharon Cooper HB 519, Step Therapy legislation. I must say that Rep Cooper is also the long term serving Chairwoman of Health and Human Services Committee who my husband served on the committee with during his time in the Georgia Legislature. He thought very highly of the Chairwoman Cooper and felt the bill was on its way to passage if she was personally carrying it.

HB 519 would limit step therapy and fail first protocols. Dorothy Leone-Glasser, who I consider a hard working stalwart, led the advocacy efforts for the bill. The diligent work of Chairwoman Cooper and Ms. Leone-Glasser paid off when HB 519 passed the House. Unfortunately, when the bill arrived in the Senate, a similar enthusiasm and passion for step therapy was lacking. The bill sat and sat in the Senate committee for several weeks. After a series of twists and turns, step therapy legislation language was placed into SB 325, which had not a thing to do with Step Therapy, but again unanimously passed the House. The fate of SB 325 ended in the Senate without passage vote. Unfortunately, during this session only the House understood the importance and impact of step therapy on those living with various chronic diseases – thank you Chairwoman Cooper! With diligent work, during the next session, I believe both the Georgia House and Senate will take action to cut through the red tape of step therapy and the insurance industry.

Most importantly – We go back to Sandy

Sandy had been taking metformin for a couple of years yet her hemoglobin A1c remained at 9%. She had sulfa allergy so she is unable to take sulfonylurea. Sandy was placed a DPP-IV inhibitor, which only lowered her hemoglobin A1c to 8.5%. After a couple of months, she was placed on GLP-1 receptor agonist. After a few months, she achieved an A1c of 7.2%. If, she had been placed on the GLP-1 agonist earlier, Sandy’s progress would be reported very differently than we are seeing today! It is worth noting that ….

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Nan, a 67 year old retired teacher with Type 1 diabetes who wears an insulin pump, came into to see me after getting off work from her part time job with an interest in a “trial run” of the latest DexCom G5 and Libre CGMs to see which the best fit was for her. I shared with Nan my recent experience with the DexCom G5, as a diabetes educator who does not have diabetes; I felt it essential to have an experience wearing DexCom G5 and Libre. This hands on experience provides me with an informed dialog beyond the basic information I read in those product brochures. So having had a couple of weeks of wearing the DexCom G5 it was now time for me to experience the Libre.

Getting it On
I must confess “getting connected” to any CGM is a bit of encounter for me! As my husband pointed out, it may be primarily because I do not read directions and my lack of technical abilities to use devices in general. Attaching the sensor to the backside of my upper arm was much easier than I had anticipated. There’s just a few simple steps….attach the sensor to the applicator, place the applicator on my arm, and press down on it to secure to my arm. To finish the sensor initiation, I scanned the reader over the sensor. Now, I had to wait 12 hours before I was able to get my glucose reading. I did much better with this sensor application as compared to the DexCom G5 sensor. However, I prefer only waiting 2 hours rather than 12 hours to see my glucose value.

Scanning My Arm
I absolutely loved getting to “scan the sensor” on my arm with the hand held reader. For the first few days, I found myself “scanning” my sensor numerous times a day. It gave me a strong sense of comfort especially, when I had a low and high glucose (for someone without diabetes). The reader advised me to do a finger stick to confirm the value before making a treatment decision. While I enjoyed not having to do finger stick calibrations twice daily, I was questioning why one CGM system would require twice daily finger stick calibrations and another would not. While I know that the product brochure clearly explains the need for or lack of need for blood glucose calibrations, I am curious as to how this can be. About six days into the wearing my Libre, my “scanning” frequency decreased significantly to just a few times per day.

OOPS! – Forgot I Was Wearing It!!!
I am not exactly sure why I forgot I was wearing the sensor just before the end of my 10-day experience, possibly due to it being on the backside of my upper arm rather than my stomach in plain sight, or not having to do a finger stick calibration? I honestly did not remember the sensor being on arm until I ran into something that almost pulled the sensor off my arm. Obviously, the novelty of “scanning” wore off for me. While I could easily see how my blood glucose trends on my cell phone with the DexCom G5, I wish the Libre afforded the same opportunity.

Back to Nan
After Nan’s experience of wearing DexCom G5 and Libre, she opted for the Libre for numerous reasons including: arm versus abdominal, no finger calibrations and scanning with the reader. Working in unison, Nan and I learned that 1) calling ahead to make sure the local pharmacy either stocks or can order the Libre sensor kit; 2) utilize drug savings cards (i.e. Georgia Drug Card-may need to activate before going to pharmacy) to decrease out of pocket costs; and 3) it’s best to go through a medical supply company if you have Medicare.

As a person with diabetes who may be interested in a CGM, inquire with your diabetes educator, endocrinologist or primary care provider to see if you could have a “trial run” wearing each of these CGMs to see which is best for your lifestyle.

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#diabetes #CGM #Libre

It was a rainy Monday afternoon when Mary phoned to share her uncontrollable excitement! Mary’s husband of twenty years had just surprised her with an anniversary gift of a 21-day trip to Italy including a Riverboat cruise. To say you could hear and sense her excitement through the phone is an understatement! I have worked with Mary for about five years as her diabetes educator in supporting the management of her Type 2 diabetes.

Near the end of the call, I sensed some concern in Mary’s voice. She was concerned about getting vaccinations for her trip as well as which medications to carry with her just in case she needed them – especially since a portion of the trip is on a cruise line. My recommendation is for her contact the local public health department regarding travel vaccines as well as the Centers for Disease Control website any travel updates. While Mary was making those contacts, I asked her to give me a day or so to work on the “just in case” medications list.

Developing “Just in Case” Needed Medications List

The most important step before purchasing the “just in case” needed medications is making sure to have a list of all your current prescription, nonprescription drugs and supplements – including name, strength and how take it.

Fever
Acetaminophen (Tylenol®) is the preferred drug. Make sure to not go over 4 grams (gms) (4000 milligrams (mg)) per day as > 4 gms may harm the liver.

Pain
Acetaminophen (Tylenol®) or ibuprofen (Advil®, Motrin®) would be appropriate. Avoid ibuprofen when chronic kidney disease or NSAID induced peptic ulcer disease is present. Acetaminophen can interfere with DexCom G5 system.

Heartburn and Upset Stomach
Antacids (i.e. Tums®) are a great option for treating heartburn and indigestion. Bismuth subsalicylate (Pepto-Bismol®) can treat upset diarrhea, heartburn, nausea and upset stomach. Heads up…it can cause black tongue and black tarry stool. Loperamide (Imodium A-D®) can treat diarrhea. If suspect food poisoning, seek out medical care rather than taking these medications.

Motion Sickness
Meclizine (Dramine®) (less drowsy formulation) and diphenhydramine (Benadryl®) are both good options for treating motion sickness. Diphenhydramine has the added bonus of treating allergies and insomnia as well. If those who have previously experienced motion sickness when flying or on cruise, plan ahead next time by requesting your primary care provider for scopolamine patch prescription before the big trip.

Dry Eye
Artificial tears are the ideal eye drops for dry eye. Watch out for dry eye especially when on long flights.

When shopping for these medications, make sure to check with the pharmacist if you have any questions or are concerned about possible drug interactions. Also, remember more is not always better when it comes to medications.

Back to Mary

I phoned Mary later in the week with her “just in case” needed medications list to ensure that she was ready for her big trip. She was grateful for the list and shared that she had an appointment for her travel vaccines next week at the local health department. She shared that she could now focus on the rest of her “to-do” list and promised to shares with me some pictures from the trip of a lifetime.

FOOTNOTE: Some traveler’s say they don’t want to pack and carry around all of those OTC products and will just wait until they arrive at their destination or wait until needed. Hunting down a pharmacy is extremely time consuming and infringes on site vital seeing time. Also, purchasing those items in a hotel sundry shop or at a ship board store is exceptionally costly – so go ahead and take care of those items before you leave home!

Please share your thoughts and comments.

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#diabetes #travel meds #fever #pain #dry eye #upset stomach

2018 Season of Colds and Cough

Bob, who has Type 2 diabetes and high blood pressure, phoned me bright and early Monday morning stating he had a cold and cough and was unsure of what product to take. It is so common to experience the sheer confusion like Bob when choosing a product to treat cold and cough. What is one to do?

Identify your Specific Symptoms

Before rushing off to the pharmacy to purchase a non-prescription medication to treat your cold or cough, slow down and identify your symptoms. Do you a:

-Cough?
Is it nonproductive or productive?
Nonproductive: dry, hacking
Productive: expel secretions
What color is the secretion?

-Cold?
Sore throat
Nasal congestion
Fever (oral temperature greater than 99.7°F)

Back to Bob, he stated that he had a sore throat, stuffy nose and dry cough for the last few days. His coughing spells had made it difficult for him to sleep through the night not to mention his co-workers’ frustration of listening to his hacking cough at the office all day – of course Bob is frustrated!

Consult with Pharmacist

Are you aware that pharmacists are medication experts and the most accessible healthcare professionals? Don’t’ be shy about discussing with the pharmacist in your local pharmacy for recommendation for non-prescription products to treat your cold or cough? Make sure to tell them your specific symptoms related to your cold or cough. Next, share with them all prescription and non-prescription (vitamins, supplements and other over the counter medications) medicines that you are currently taking as well as any drug allergies.

Stay AwayFrom

The old notion of taking large doses of vitamin C or drinking orange juice to prevent or treat colds simply is not true. Sore throat lozenges or liquid cold non-prescription medicines will treat your symptoms plus leave you with high blood sugar – go with only sugar free syrups and sore throat lozenges. If you have been diagnosed with high blood pressure, avoid decongestants (pseudoephedrine, phenylephrine, oxymetazoline) (as they will raise your blood pressure).

General Tips

– Read Drug Facts Label carefully
o Look for the primary ingredients
• For dry cough: dextromethorphan and diphenhydramine
• For acute, ineffective productive cough: guaifenesin
• For nasal congestion: nasal saline rinse
• For sore throat: lozenges (benzocaine, dyclonine, menthol)
• For fever: acetaminophen (Tylenol®)
– Less is better:
o Pick product with only the primary ingredients needed to treat your symptoms
o Fewer the primary ingredients the better
– Hand washing is vital. While washing hands with soap and water is ideal, cleaning hands with hand sanitizer is a great alternative.
– Don’t over do the acetaminophen (Tylenol®)
o Did you know that many nonprescription combination products used in treatment of colds already has acetaminophen included in it?
o If taking a combination product, usually no need to take any acetaminophen
o Stay under 4 grams (4000 milligrams (mg)) per day

Back to Bob

My recommendation for Bob was to purchase a saline nasal rinse for his stuffy nose, sugar-free sore throat lozenges and dextromethorphan for his dry cough. He phoned a few days later stating that he was beginning to feel better and getting a good night’s sleep without waking to cough spells – and he said his co-workers are happier as well!

Please share your thoughts and comments.

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#diabetes #clearing confusion #colds #medicine

Sue, who has Type 1 diabetes and uses an insulin pump, had been asking about a continuous glucose monitor for about the last year. She previously wore a CGM that paired with her insulin pump prior to having insurance through Medicare (Medicare would not cover CGM for Sue). She really wanted her CGM back. Due to Medicare not covering the CGM that Sue previously wore, she and I discussed the Dexcom G5 CGM system (how it works, benefits, etc.) and the possibility of Medicare paying for this system beginning in 2018.

For those of you unfamiliar with CGM, CGM is a tool that tracks trends in glucose. The sensor reads the glucose every 5 minutes, which allows the person with diabetes to see in real time the pattern of their glucose. This valuable information is particularly useful for those who wear an insulin pump as they can make adjustments to pump based on the current glucose pattern to prevent highs and lows.

During the process of investigating the Dexcom G5 for Sue, I became curious as to what it would be like to wear a CGM. As a diabetes educator, I find it essential to the extent possible to walk in the shoes of those with diabetes in particular those who wear insulin pumps and/or CGMs. Having had an insightful experience wearing an insulin pump (using normal saline of course) previously, I was eager to wear a CGM for at least a week. When I reached out to Matt, a rep for Dexcom, on behalf of Sue, I shared with him about desire to experience wearing CGM for a week or so. He was agreeable and made it happen!

Time to Hook Up

Guess what…I wore a dress (not such a good idea when starting a CGM in clinic) the day I was supposed to start wearing CGM so I had to wait to hook up the CGM until the evening. The company representative was gracious and reviewed with me the details of the CGM. I thought, this is pretty simple and should be easy to hook up and use. I planned to attach CGM and start that evening, except that I got distracted, so I actually started the next morning. I had difficulty remembering how to attach the CGM to my body; however, I recalled the “how to” video on the app. After about 20 minutes (should have only took 1-3 minutes…user challenge), I had the CGM attached and working. Now I needed to remember to calibrate in two hours (thank goodness for the reminder).

Oh My…First Nighttime Low

My friend, Pati (who has Type 1 diabetes and currently wears an insulin pump and CGM), said “at least you do not have to deal with nighttime alarm for low or high glucose when I told her I was wearing CGM. “ So much for not having a night time low…it slipped my mind that a couple of glasses of wine with dinner and no bedtime snack might cause me to dropped low. Around 3 am, I almost jumped out of bed when my phone alarmed. I grabbed my phone quickly to find my glucose had dropped to 48 mg/dL. Not only did it wake me, I also awoke my husband had no idea that I was even wearing the monitor! Needless to say, I watched the wine more closely and had a bedtime snack after that experience.

Riding High

At this point, I must admit that I love to eat sweets especially around Thanksgiving and Christmas. Well, what a perfect time of year, Thanksgiving, to be wearing CGM to see what these “yummy” treats really do to my glucose – especially if I overindulge! My office had an “international” Thanksgiving lunch with lots of diverse delicious food. I ate more than usual in process of sampling as much of the various foods. I “hit the ceiling” when my phone alarmed with glucose of 188 mg/dL (keep in mind I do not have diabetes so 188 mg/dL is too high for me). I immediately racked my brain in attempt to recall everything I ate over the last several hours. I felt guilty and frustrated at that moment. Ah… for just a moment, I felt in a small way what a person living with diabetes feels when they have a “high.”

Obsessed…. Constantly Checking iPhone

During my two week experience of wearing CGM, I constantly grabbed my phone to see what my glucose was trending. This impulse comes from my obsessive tendencies and eagerness to see the actual numbers themselves. As background, I previously had prediabetes and took metformin however thanks to lifestyle changes I no longer have prediabetes. Based on the many glucose values and trends that I saw on my app, I can confidently say that I no longer have prediabetes (also, my A1c is < 5.7%). Having the numbers (data) from the CGM is invaluable, I can not even imagine what it must be like for a person living with diabetes to have this information.

As my two-week trial came to an end, I was saddened to remove the CGM as I found the real time numbers and data it provided plus the bonus of seeing what impact various foods have on my glucose. I downloaded my glucose report for the two weeks, which left me feeling thankful for this experience. To finish the experience, I had to remove the transmitter and sensor, which proved to be a challenge. Needless to say, I did not remove it appropriately, however, I did get it removed.

Back to Sue, she is still pursuing CGM specifically Dexcom G5 system as Medicare will reimburse for this in 2018. Wishing for Sue to get her Dexcom G5 system in 2018 as well as for Medicare to reimburse for various CGMs for those living with diabetes on Medicare insurance. Happy New Year 2018!   #wearing CGM   #hand on experience #Medicare

Guess what! November is American Diabetes Month!!! Yes, an entire month to celebrate patients with diabetes. The American Diabetes Association is conducting a terrific campaign to focus on Diabetes – a letter writing campaign about what you want to say to Diabetes.  Do you want to share with the world how diabetes makes you feel? To do so, share your letter or video letter on any of your favorite social media using #DearDiabetes.

In honor of American Diabetes Month, I have a diabetes story to share from a diabetes educator viewpoint.  After wrapping up a great diabetes meeting in Chicago, along with a little personal time with my husband, it was time to head back home to Georgia. We caught an Uber ride to O’Hare to catch our late Sunday afternoon flight.  You know those initial awkward moments after hopping into an Uber – the luggage barely fit into the trunk, no leg room in the back seat, and blaring music that I couldn’t even understand the words). I wondered whether I should talk or not with the Uber driver, so I glanced over to see my husband reaction the music to my surprise he was looking straight head anticipating the trip back home and appearing to have tuned out the loud noise our driver called music.

As a true southern gal, I tend to jump into conversations rather easily as I have a true gift of gab.  The usual small talk commenced with my asking the driver about his work and hobbies.  Michael, the Uber driver, asked why I was in Chicago, so I excitedly shared with him about my serving on a board for a national diabetes organization. This opened the door to share my passion for diabetes education and my desire to help those with diabetes.  I had opened Pandora’s box without realizing it.  Looking back through the rearview mirror at me, with great curiosity he asked the question, “what are the signs and symptoms of diabetes?”  Without realizing what was about to happen, I had just opened the door for a very important conversation with this young man! In keeping it simple, I did my usual short summary when I have patients or students ask this question…being really thirsty, urinating a lot, and blurry vision.

Okay, we all know that this is not the complete list, but these are three major symptoms.  Again looking up in his review mirror he asked,”I wonder if I have diabetes?” He went to share. “When I worked at a paint factory, I would get nauseous sometimes and it got really bad a couple of times.  My boss said I had to get checked out to make sure I was okay.”  He said all of the tests came back normal. His story continued..”I do remember that I felt better after I drank some Sprite. Maybe I have diabetes?” I reassured him that he most likely does not have diabetes but rather maybe experiencing hypoglycemia (aka low blood sugar).  I described it as feeling shaky, dizzy, and like you are going to pass out.  He connected with these signs and symptoms. So I asked Michael, “… do you go long periods without eating?” He replied, “Yes, I feel this way when I am working out if it has been too long since I last ate.”  I encouraged him to eat a snack before working out, not to go more than 4 – 6 hours without eating, and make sure to have protein (i.e. cheese, nuts, meat) with each meal and snack.  Michael was grateful for the information I had shared with him.  And as always, I encouraged him to have regular checkups with his general practice physician!

A simple Uber ride to O’Hare provided an opportunity to share with Michael the seriousness of diabetes and low blood sugar- not to mention that the great conversation made the traffic seem not as bad! A great close to a great trip to Chicago!

#DearDiabetes #DiabetesMonth  #reecespiecesinadiabetesworld

 

In this second of a three part series on affording diabetes medications, an overview of websites, medication discount programs, and prescription discount cards are all highlighted. I have found numerous websites that exist to assist people with an array cost saving options for medications. Below is a short list of some of the most common websites and the key points for each.

o GoodRx (www.goodrx.com)
• Compare drug prices to locate a local pharmacy with lowest cash price for a specific medication (put in drug name, quantity and zip code) for your home area.
• GoodRx coupons will help lower the overall cost of prescriptions. Print coupon and bring with you to your pharmacy.
• However, Coupons will NOT lower your copay if you have insurance.
• If you are a techie an App is available!

o BlinkHealth (www.blinkhealth.com)
• Anyone can use – regardless of insurance status.
• Good ONLY for generic medications.
• Search for medication and pay online at website.
• Name and date of birth on your BlinkHealth account must match your prescription.
• Print out blink card and bring with you to your local pharmacy. Copay will be $0.
• Refundable purchase.
• Mobile App is available.

o NeedyMeds (www.needymeds.com)
• Helps people locate assistance programs to purchase their medications and contain other healthcare costs.
• Works with patient assistance programs of several pharmaceutical distributors.
• Good for prescription medications as well!
• No registration required.

o American Association of Clinical Endocrinologists (AACE) Prescription Savings Directory (http://prescriptionhelp.aace.com/)
• A list of branded endocrine –related medications name drugs that have discount or rebate program.
• Easily accessible in alphabetical order.

o RxAssist (www.rxassist.org)
• Patient Assistance Program Center.
• Offered by CMS.
• A list of brand name drugs that have discount or rebate program.
• Easily accessible, in alphabetical order.

There are numerous prescription discount cards available that provide medication cost savings. Partnership for Prescription Assistance (https://www.pparx.org/prescription_assistance_programs/savings_cards) is a website that provides a lists of prescription savings cards. A sampling of only a few of the many available prescription savings cards is below.
• Better Rx Card (www.betterrxcard.com)
• Georgia Drug Card (www.georgiadrugcard.com)
• Discount Drug Network (www.discountdrugnetwork.com)
• Easy Drug Card (https://easydrugcard.com/)
• App Available
• WebMD Rx Savings Card (https://www.webmd.com/rx)
• App Available
• Drugs.com Discount Card (https://www.drugs.com/discount-card/)

Lastly, some pharmacies offer prescription savings clubs or rewards programs. These clubs or programs are particularly useful if patients get all of their prescriptions filled at the particular pharmacy. Below is a list of a few national programs.
• Walgreens Prescription Savings Club
• Kmart Pharmacy Rewards
• Rite Aid Rx Savings Program

As a diabetes educator, I have assisted numerous patients with getting prescription drug assistance information and forms through needymeds.org as it is easy to use and has all of the available assistance program details in one place. Also, I explain how to complete paperwork and required documentation for each patient. If you are an educator or provider, I highly encourage you to guide patients through this process as it can be very confusing. If you are a patient, reach out to your diabetes educator or provider for assistance navigating this process.

To be savvy in saving money on prescription medications, a little homework before going to the pharmacy is key. Make sure to check the websites listed above and check for available prescription discount cards in your area. Also, investigate savings clubs or rewards program with your local community pharmacies. These tools in your savings toolbox will take the pressure off your wallet. #savingmoney   #NeedyMeds  #BlinkHealth #GoodRx   #RxAssist #PrescriptionHelpAACE #discoundcards