Dexcom G5 and Medicare

so humana is now paying for your G5 thru solara?

No, not the G5 the G4 until they figured out that Medicare did not cover
Dexcom CGM system, but after Medicare approved only the G5 for Medicare
members I contacted Solara to try for an upgrade and I was told that only
Dexcom could process G5ā€™s for Medicare members, which took Solara and other
3rd party distributors out of the loop. I am going to call or email Solara
and find out if they still restricted on ordering the G5 sometime next week.

Bob

u can try this too. go to your plan >zip code. humana.com>find a provider>other health providers> sub-listing Durable medical equipment> search out 100 miles. I see CCS Medical as being ā€œin networkā€ . I donā€™t see dexcom listed.

could vary by zip? a little clue

@ann21

Dexcom is currently the sole distributor for Medicare. At this point, Dexcom is not shipping to customers with the Advantage plans other than the pilot program with UHC as mentioned above.

dexcom is shipping to kaiser medicare advantage

@ann21
That is awesome !!! Thanks for the update.

Do you have some links, articles or news releases you can share that would provide additional details?

I guess what I donā€™t understand is that the Advantage Plans like Humana have
a contract with Medicare as providers to some of their members. So how hard
is it for Dexcom to replace Medicare name with the Advantage Plan such as
Humana. I mean if Humana as a contract with Medicare to provide coverage to
Medicare members how confusing can this be. Like I said before I am just
glad with the help of others that I can still use my G4. After all, as I
understand it.with the exception of Medicare paying for the G5 I will gain
nothing more.from having the G5.

Bob

G4 or G5 - same sensor, same algorithm, same consistency, same accuracy.

G6 - (when approved and released) - different story.

The G6 may be something to look forward too, but if Medicare has their way
its members will be using the G4 again. As you can see I donā€™t have a lot
of faith. Maybe they will let us old folks use the mobile feature with the
G5, lol/

@Bob_Martin
Actually, the G6 should be approved for Medicare right out of the gate. It will carry the same FDA approval of a therapeutic cgm (ie - bolus decision from cgm without requiring a fingerstick)

As well, even before the Smartphone issue gets worked out, I would expect to have clarification and specific guidance which allows Medicare recipients to use the Dexcom G5 (and upcoming G6) integrated with pumps. The Medicare ruling never explicitly says this is not allowed so this should not be a big deal to have clarified.
This will likely become a bigger issue when Tandem releases the Basal-IQ (formerly PLGS) update this Summer which of course requires the Dexcom G5 integration. Right now the Tandem/Dexcom integration is about some minor convenience. However the Summer 2018 update from Tandem will be quite functional and will rightly deserve to be used by everybody who has the Tandem and Dexcom regardless of what the insurance coverage funding is used to obtain those devices.

Kaiser is 5 star u can switch anytime during year to any 5 star in your area . Kaiser g5 prices 73 mo, vs original Medicare about 55/mo if no medigap supplement. Kaiser g5 receiver price 75.

@ann21

Thanks for the additional information.

Would you be able to provide specific weblinks that would provide further details on the points you raise? This would be really great to read more about.

https://www.medicare.gov/sign-up-change-plans/when-can-i-join-a-health-or-drug-plan/five-star-enrollment/5-star-enrollment-period.html

so what is going on is good question. the devil is in the details is best explanation. dexcom applying diff codes to advantage. think my math above is not quite right. this is from my notes check numbers, I did on the fly, LOL. kaiser I called and they refer to durable medical equipment dept. she said co-pay for G5 is 20% just like original medicare. dexcom is their supplier. receiver is $370 so 20% so $74 to patient. sensors/trans are 90 days.
trans come in bundle of 2 at 399. so 4 trans per year would $160 to patient, 80 2x yearly then. each trans last 112 days, so 4th transmitter crosses the 365 days, some slop there.
box of 4 sensors 240, 3 boxes sensors for 90 days, or 240x12 for one box per month is 2880 so $576 to patient. so 48/mo or 144 every 90.

total cost of G5 to patient for one year at kaiser=$810 to patient under medicare part B (68/mo). or if have receiver already, then order 144 every 90 for sensors, and order transmitters twice a year at 80. so your bill would look like this:
1 jan sensors+transmitters=144+80=224
1 april sensors=144
1 july sensors+transmitters= 144+80=224
1 oct sensors=144.
total $736 per year, 61 per mo for planning purposes.

add 1 receiver 370*20%=$74 to patient. G5 receiver is the durable supposed to last 4 years. perhaps if change plans alot, next plan sells you receiver that 370 is on you perhaps, if you accept a upgraded model (??) no idea just throwing that out there.

in case you donā€™t come into plan on Jan1, redo numbers accordingly. actually need 52 sensors per year at mandated fda changeout at 7 days, so thatā€™s only 48 sensors if 1 box/mo. so we really need 1 more box of 4 sensors each year, guess we call that medicare mystery math, LOL !!!

talk about billing: dexcom billing G5 yearly: consider total costs not just your co-pay.
$370 receiver medicare advantage, vs $250 original medicare, so if they sell 20000 patients a receiver $74000000 at 370/per medicare advantage patient.
20000 patients a receiver $5000000 at 250/per original medicare patient.

80% goes to medicare/med adv while 20% paid by patient. thats just the receiver. no idea what the ratio is, but higher billing code is the issue. thats just the receiver.

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@ann21
That is a lot of information. All great.

But I am still wondering if you have a link that says that a particular Medicare Advantage plan (other than the pilot program I earlier posted about) is providing coverage for the Dexcom G5 cgm system?

kaiser is only one with details so far. calling around, Iā€™ll post my findings this week.

@ann21

Ann, rather than a post of your findings, if you could post a weblink that would provide details of anything that you have said that would be great.