ACA Insurance Coverage: From Syringes to Pump

Diabetes Technology Insulin Pumps
1

I am a 29 year old T1 diabetic. For a long time I have been uninsured and had been injecting with syringes and vials since it was the cheapest thing. I would go through elaborate processes to get my vials for cheap ($2) from a hospital in Brooklyn and pay for syringes out of pocket (around $60 per hundred in NYC). Then 2014 came around and I could get health insurance thanks to the ACA.

The Different Options
They had a bronze, silver and platinum plan. I cost out each plan considering my prescriptions, the prescription co-pay for each plan and the durable medical equipment coverage for each plan. In the end, considering the costs over a year and the fact I wanted to upgrade my equipment, the cheapest plan for the year turned out to be the Platinum plan.

I enrolled with Blue Shield of California. I am paying about $350 a month. I pay $15 co-pay for prescriptions and 10% of the durable medical equipment cost. I pay $40 to see a specialist (Endocrinologist) and $20 to see a physician. For the whole year my deductible maximum is $4000. As a side note, I had a run in at the urgent care (cut finger) and the visit and stitches were completely covered. I assume the coverage in other states are around the same since Blue Shield said if I moved back to New York they would just transfer my coverage

Getting a Pump and CGM
I met with an endocrinologist and she switched me to the Pen for Lantus and Humalog. We scheduled a trial run of the I-Pro sensor to get good data. I wore the I-pro for 3 days and turned it in. I met the endo again to discuss the data and put out information to Dexcom and Tandem. About 2 weeks later Dexcom and Tandem contacted me. I had to give them some glucose logs and forms. A week later Dexcom sent my CGM. I am waiting for Tandem to get back to me next week

The Dexcom G4 was $128 to start, $28 for 4 sensors. Its working really well so far. The Tandem T Slim pump should be coming in soon. It was around $425 to start, $38 for 3 months worth of cartridges. Vials of Humalog will be $15 per vial under my co-pay.

2

Thank you for making such a detailed report for a T1D gaining access to health care under the Affordable Care Act. I have always had access to health care with insurance picking up a very large percentage of the bill. As a result I've been able to use the latest tools for care. I use an insulin pump (27 years), a CGM (almost 5 years), and expensive analog insulin.

Managing blood glucose is always a struggle. You proved resourceful when times were tough but I can imagine others in your situation didn't respond with your admirable resilience.

I'm happy to read your account since I know your story represents so many others in our tribe. Good for you! Best of luck with all your new tools. Consider this site as valuable resource.

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Thus far, I've been having a slightly different experience with how the AFA may be affecting my own prescriptions, and thought I would post about it, if anyone could relate/had any insight (my apologies if this is recycling something from another post...)

So I too am on Blue Shield of CA, a Gold-level plan (which I just switched to from Anthem Blue Cross).

I use a Medtronic/Minimed insulin pump and for the longest time, I was really getting taken advantage by Blue Cross every time I'd ordered supplies-- infusion sets, reservoirs, adhesive tape-- paying like $200 for a $230 shipment. Finally one of their agents did me a kindess and submitted as a Prescription through their mail-order department, Express Scripts. I'd get regular shipments mailed every month, but it was a bit less.

Fast-forward to now, Medtronic says they're no longer contracted with Express Scripts, and Blue Shield isn't either (their mail-order provider is Primemail). I get a prescription for my pump supplies from my doctor and mail it to them, yet they mail me back, saying it's denied. They're trying to just bill it as Durable Medical Supplies. For 2 boxes of infusion sets billed at $189.20, they only paid $48.60, and didn't pay a dime for my $65.49 box of adhesive tape. So basically for a $267 order, they only paid around $53.

I originally chose the Gold plan because I was going to be paying some $2000 before they paid ANYTHING for my pump supplies, but it turns out they're hardly paying anything for that as well (and the fact that they denied it as a Prescription benefit is even more infuriating...).

I HEARD somewhere that if you signed up for an insurance company WITHOUT using the AFA (and their tax discounts), the plan benefits changed to your advantage, but an insurance agent also told me otherwise... anyone know??

Anyway, anyone who's also experienced this (with or without Blue Shield), and has any advice, I would love to hear from you. Thanks!!