Does Security Health Plan Cover Metformin?

What Security Health Plan Is and Why Formulary Details Matter

Security Health Plan of Wisconsin is a regional nonprofit insurer headquartered in Marshfield, Wisconsin, offering commercial, marketplace, Medicare Advantage, and employer-sponsored group plans across much of the state. Like every insurer operating under the Affordable Care Act, Security Health Plan maintains a formulary, which is a tiered list of covered drugs that determines your out-of-pocket cost at the pharmacy counter.

Formularies are not static. Security Health Plan reviews its formulary at least once per year, and mid-year additions or removals are possible. A drug can move from Tier 1 to Tier 2 or lose coverage entirely between plan years. The practical consequence: the coverage details in this article are based on publicly available 2024 and 2025 plan documents, but you should confirm current tier status and cost-sharing directly through the Security Health Plan member portal at SecurityHealth.com or by calling the member services number printed on your insurance card.

Metformin, however, has held preferred generic status on nearly every commercial formulary in the United States for the better part of two decades. Its inclusion on the Security Health Plan formulary at Tier 1 is consistent with national prescribing norms and the drug's status as the first-line pharmacological agent for type 2 diabetes according to the American Diabetes Association (ADA) Standards of Care. The ADA's 2024 Standards of Medical Care in Diabetes state explicitly: "Metformin, if tolerated and not contraindicated, is the preferred initial pharmacologic agent for the treatment of type 2 diabetes." [1]

What "Covered" Actually Means: Tiers, Copays, and Deductibles

Security Health Plan uses a multi-tier formulary structure. Tier 1 contains preferred generics and is associated with the lowest member cost-sharing. For most commercial plans, that translates to a $0 to $10 copay per 30-day fill at an in-network pharmacy. Medicare Advantage plans may structure cost-sharing differently, sometimes offering $0 copays for Tier 1 drugs in the initial coverage phase of Part D benefits.

Here is how the tier structure maps to out-of-pocket cost in a representative Security Health Plan commercial design:

• Tier 1 (Preferred Generic): $0 to $10 per 30-day supply
• Tier 2 (Non-Preferred Generic / Preferred Brand): $30 to $50 per 30-day supply
• Tier 3 (Non-Preferred Brand): $60 to $100+ per 30-day supply
• Tier 4 (Specialty): 20 to 33 percent coinsurance

Generic metformin hydrochloride immediate-release (IR) tablets, available in 500 mg, 850 mg, and 1 to 000 mg strengths, typically land at Tier 1. Metformin extended-release (ER or XR), sold under brand names such as Glucophage XR and Fortamet, may sit at Tier 2 or higher on some Security Health Plan designs, particularly for brand-name dispensing.

One critical caveat: if your plan has a deductible that applies to drug benefits (common in high-deductible health plans), you will pay the full negotiated drug price until you meet that deductible, even for Tier 1 drugs. Once the deductible clears, the standard copay applies. For a 90-day supply of generic metformin 1 to 000 mg, the negotiated price at major retail chains often falls between $10 and $25 without insurance, meaning even in a deductible year the cost remains low.

The Medical Evidence Behind Metformin: Why Insurers Cover It Readily

Insurers place metformin at Tier 1 partly because of cost (it is cheap to manufacture) and partly because of overwhelming clinical evidence supporting its use. Understanding that evidence helps when advocating for coverage.

The UKPDS 34 trial, published in The Lancet in 1998, enrolled 1,704 overweight patients with newly diagnosed type 2 diabetes. The overweight group assigned to intensive metformin therapy showed a 36% reduction in all-cause mortality compared to conventional diet therapy (P<0.01). [2] That single trial cemented metformin's first-line status for decades.

The Diabetes Prevention Program (DPP), a landmark randomized controlled trial (N=3,234) funded by the National Institutes of Health, demonstrated that metformin 850 mg twice daily reduced the incidence of type 2 diabetes by 31% over 2.8 years compared to placebo in adults with impaired glucose tolerance. The lifestyle intervention arm reduced incidence by 58%, but metformin remained significantly superior to placebo (P<0.001). [3] This trial is why the ADA recommends considering metformin for prediabetes, particularly in adults under 60 years old, those with BMI <35 kg/m2 who are overweight or obese, and women with a history of gestational diabetes. [4]

More recently, metformin has attracted attention in longevity research. The TAME (Targeting Aging with Metformin) trial, a multi-site Phase 3 study funded through the American Federation for Aging Research and registered at ClinicalTrials.gov (NCT02432287), is currently enrolling approximately 3,000 adults aged 65 to 79 to test whether metformin can delay the onset of age-related chronic conditions. Results are expected around 2026. [5] Security Health Plan does not currently list longevity or anti-aging as a covered indication, but the growing evidence base reinforces metformin's broader clinical value.

Covered Indications vs. Off-Label Use: What Security Health Plan Will Pay For

Security Health Plan, like virtually all U.S. health insurers, ties prescription drug coverage to a medically accepted indication documented in your prescriber's notes. The FDA approved metformin for type 2 diabetes mellitus in adults and for pediatric patients aged 10 and older. [6] That is the primary covered indication.

Off-label uses, including polycystic ovary syndrome (PCOS), prediabetes, weight management, and longevity protocols, occupy a gray zone. Coverage for off-label prescriptions depends on whether the indication appears on recognized compendia such as the DRUGDEX (Micromedex) or Clinical Pharmacology databases, which insurers consult when adjudicating claims.

PCOS is the most commonly covered off-label indication for metformin at Security Health Plan, provided the diagnosis is clearly coded on the prescription or prior authorization form (ICD-10 code E28.2 for polycystic ovarian syndrome). The ADA and the American Association of Clinical Endocrinology (AACE) both note metformin's role in insulin-resistant PCOS patients, giving payers clinical cover to approve it. [7]

Prediabetes coverage is less consistent. Some Security Health Plan commercial plans cover metformin for prediabetes when the prescriber documents impaired fasting glucose (ICD-10 R73.01) or impaired glucose tolerance (ICD-10 R73.09) and notes the DPP trial rationale. Others require a diabetes diagnosis code for coverage to trigger. Calling Security Health Plan's pharmacy benefits line before filling the prescription saves time and prevents unexpected bills.

Pure longevity or anti-aging prescriptions are unlikely to be covered under the current formulary framework, because no ICD-10 code maps to "longevity optimization." Prescribers sometimes use metabolic syndrome (E88.81) or insulin resistance (E11.65) codes to justify coverage, but that strategy carries documentation risk and should only be used when clinically accurate.

Prior Authorization: When You Need It and How to Get It

For most members prescribed immediate-release generic metformin for type 2 diabetes, Security Health Plan does not require prior authorization. The drug's Tier 1 placement and well-established clinical use make PA unnecessary at standard doses (up to 2 to 550 mg per day in divided doses).

Prior authorization becomes more likely in three situations:

1. Extended-release brand-name formulations such as Fortamet or Glumetza may require PA or step therapy, meaning you must first try and document failure or intolerance of the generic IR formulation.
2. High-dose prescriptions above standard daily maximums, though these are uncommon.
3. Off-label indications where the prescriber has not provided adequate clinical documentation.

If PA is required, your prescriber's office typically submits a PA request through the Security Health Plan provider portal or by fax. The standard turnaround is 72 hours for non-urgent requests. Urgent PA requests must be resolved within 24 hours under Wisconsin insurance regulations. When submitting, the prescriber should include the relevant ICD-10 diagnosis code, recent lab values (hemoglobin A1c, fasting glucose, or OGTT results), and a brief clinical rationale citing evidence such as the DPP trial if the indication is prediabetes. [3]

The HealthRX PA Documentation Framework for Metformin Prior Authorization:

Step 1. Diagnosis clarity. Confirm the prescriber is using the most specific ICD-10 code available. E11.9 (Type 2 diabetes without complications) is universally accepted. R73.01 (Impaired fasting glucose) works for prediabetes with DPP-level evidence attached.

Step 2. Lab evidence. Attach a recent HbA1c result (for type 2 diabetes, typically 6.5% or higher; for prediabetes, 5.7 to 6.4%) or a fasting plasma glucose result. Security Health Plan reviewers look for objective data, not just clinical impression.

Step 3. Trial and failure documentation (for ER formulations). If the member genuinely could not tolerate IR metformin due to gastrointestinal adverse effects (nausea, diarrhea, cramping), the prescriber should document onset of symptoms, dose at which they occurred, duration of trial, and clinical decision to switch. The standard trial duration Security Health Plan reviewers expect is at least 4 weeks.

Step 4. Compendia citation (for off-label uses). Reference DRUGDEX or Clinical Pharmacology compendia support for the indication. For PCOS, cite the Endocrine Society's 2023 Clinical Practice Guideline on PCOS. [7]

Step 5. Appeal preparation. If PA is denied, request the denial reason in writing immediately. You have 180 days to file an internal appeal under ACA rules, and Wisconsin law provides access to independent external review after exhausting internal appeals.

What to Do If Your Metformin Claim Is Denied

A denial is not a final answer. Federal and Wisconsin state law give you structured appeal rights. The process moves in clear stages.

Internal appeal. File within 180 days of the denial notice (or sooner, per your plan documents). Your prescriber submits additional clinical information. Security Health Plan must respond within 30 days for pre-service appeals and 60 days for post-service (already filled) claims.

Expedited appeal. If your clinical situation is urgent, the timeline compresses to 72 hours. Urgent means a standard timeline could seriously jeopardize your health or ability to regain maximum function. A patient newly diagnosed with type 2 diabetes who cannot afford alternative agents qualifies.

External independent review. Once internal appeals are exhausted (or if Security Health Plan fails to meet response deadlines), you may request an independent external review through the Wisconsin Office of the Commissioner of Insurance (OCI). The OCI assigns a certified independent review organization (IRO) whose decision is binding on the insurer under Wisconsin Statute 632.835.

Exception requests. Separate from the appeal process, formulary exceptions allow coverage of a non-formulary drug or a lower cost-sharing tier when your prescriber documents medical necessity. If you have a documented intolerance to generic metformin and need a specific brand or formulation, a formulary exception is the correct pathway.

For metformin specifically, the appeal success rate tends to be high when documentation is thorough. The drug is cheap, widely used, and supported by multiple guideline endorsements. Reviewers at Security Health Plan have limited clinical grounds to deny a properly documented claim.

Cost Without Insurance and Assistance Programs

If coverage falls through entirely, metformin remains one of the most affordable drugs in the U.S. market. Generic metformin IR 1 to 000 mg, 60 tablets (a 30-day supply at twice-daily dosing) retails for roughly $10 to $20 at GoodRx-negotiated prices at chains such as Walmart, Costco, and Kroger pharmacies.

Walmart's $4 generic prescription program covers metformin 500 mg and 850 mg (30-day supply) and metformin 1 to 000 mg (up to a 90-day supply) at $10. This is available without any insurance and requires no membership beyond a standard Walmart pharmacy account.

The Mark Cuban Cost Plus Drugs Company (costplusdrugs.com) lists generic metformin 500 mg (60 tablets) at approximately $5 to $7, with transparent pricing that includes their standard 15% markup over manufacturing cost. No prior authorization or insurance required.

For patients enrolled in Medicaid or the Wisconsin BadgerCare Plus program (Wisconsin's Medicaid expansion), metformin is covered as a preferred drug with nominal or zero cost-sharing. The BadgerCare Plus Preferred Drug List places generic metformin IR at preferred status with a $3 or $0 copay depending on the member's income category. [8]

Metformin Dosing, Safety, and Monitoring: What Security Health Plan Members Should Know

Coverage approval often runs smoother when the prescribed regimen aligns with FDA-approved dosing parameters. The FDA-approved adult dosing range for metformin IR is 500 mg twice daily titrated over 4 to 8 weeks to a maximum of 2 to 550 mg per day in divided doses with meals. The maximum dose of 2 to 000 mg per day is often cited as the practical ceiling because additional glycemic benefit above 2 to 000 mg is modest while GI side effects increase. [6]

Metformin is contraindicated in patients with an eGFR <30 mL/min/1.73 m2 and should be used with caution (dose reduction considered) when eGFR falls between 30 and 45 mL/min/1.73 m2. The FDA's 2016 label revision removed the absolute serum creatinine cutoff and replaced it with eGFR-based guidance. [6] Security Health Plan may require a recent renal function panel (basic metabolic panel or CMP) in the prior authorization record for patients over 70 or those with known chronic kidney disease, because the insurer's medical necessity criteria often reference FDA labeling.

Vitamin B12 deficiency is an underrecognized long-term adverse effect of metformin. The ADA recommends periodic B12 monitoring in patients on long-term metformin therapy, particularly those with peripheral neuropathy or anemia. [1] This monitoring is typically covered under Security Health Plan's laboratory benefit, coded as a medically necessary diagnostic test, not a preventive screening. The coding distinction matters for cost-sharing under plans with separate deductibles for diagnostic services.

Dr. Victor Montori, a diabetes researcher at Mayo Clinic, has noted: "Metformin's durability, safety record, and cost profile make it the reference standard against which newer agents are measured, not because newer agents aren't useful but because metformin's track record spans six decades." [9]

Medicare Advantage and Part D Coverage Through Security Health Plan

Security Health Plan offers Medicare Advantage plans with integrated Part D prescription drug coverage in select Wisconsin counties. For Medicare members, metformin falls under Part D (the drug benefit), not Part B (the medical benefit), in nearly all dosing scenarios.

On Security Health Plan's Medicare Advantage formularies, generic metformin IR is consistently placed at Tier 1 with a $0 copay during the initial coverage phase (up to the 2025 initial coverage limit of $2 to 000 in total drug costs, after which the Inflation Reduction Act's $2,000 out-of-pocket cap applies). [10]

For Medicare members, the Low Income Subsidy (LIS), also called Extra Help, can reduce or eliminate drug costs even if standard cost-sharing applies. Members who qualify for Extra Help pay no more than $4.50 for generic drugs at any Part D-participating pharmacy. Applications for Extra Help are processed through the Social Security Administration.

One common point of confusion for Medicare members: metformin prescribed for metformin-associated indications beyond type 2 diabetes (such as PCOS in a Medicare-eligible patient, which is rare but possible in a 65-year-old with persistent PCOS) may face additional scrutiny because Part D coverage rules require a medically accepted indication. The prescriber's documentation and diagnosis coding carry the same weight described in the prior authorization section above.

Pharmacy Network Considerations: Where You Fill Matters

Security Health Plan designates preferred and non-preferred pharmacy networks. Filling a prescription at a preferred network pharmacy (often large chains such as Walmart, Walgreens, CVS, or Costco within Wisconsin) triggers the lowest cost-sharing tier. Mail-order pharmacy, typically a 90-day supply, often costs the same as or less than two 30-day retail fills, making it economically advantageous for maintenance medications like metformin.

Specialty pharmacies are not relevant for metformin, since it is not a specialty drug. However, if you use a compounding pharmacy (for a specific concentration or formulation not commercially available), that prescription is almost certainly not covered by Security Health Plan's standard formulary. Compounded medications require separate coverage approval and are often excluded entirely.

The difference in out-of-pocket cost between preferred and non-preferred pharmacy for a Tier 1 drug can range from $0 to $20 per fill. Over a year of twice-daily metformin, that adds up to $0 to $240 in avoidable cost. Choosing a preferred pharmacy is the simplest cost optimization available to any Security Health Plan member.

Practical Steps Before Your Next Pharmacy Visit

Verifying coverage takes under 10 minutes when you know the right tools. The Security Health Plan member portal at SecurityHealth.com includes a drug cost estimator that accepts the drug name, strength, quantity, and your specific plan code, then returns the exact estimated copay at any in-network pharmacy. The tool reflects real-time formulary data and is updated more frequently than printed formulary documents.

Alternatively, call the member services number on your insurance card and ask specifically: "Is NDC code 00093-1048-01" (a common generic metformin 1 to 000 mg NDC) "covered under my plan, at what tier, and what is my estimated copay at a preferred pharmacy?" Providing the NDC code rather than just the drug name eliminates ambiguity and speeds the call.

Your prescriber's office can also submit a coverage inquiry electronically through the SureScripts or CoverMyMeds platforms before writing the prescription. This real-time benefit check surfaces tier status, copay, and any PA requirements at the point of prescribing, preventing a surprise at the pharmacy counter.

The single most important action: if your Security Health Plan plan has a deductible that applies to drugs, ask the pharmacist for the negotiated (contracted) price rather than the retail sticker price. For generic metformin, the negotiated price is almost always lower than the list price, and in some cases using a GoodRx coupon at the same pharmacy is cheaper than running the claim through insurance during the deductible phase. You cannot use GoodRx simultaneously with insurance, but you can choose whichever is lower.