Has anyone requested and gotten their DME cap lifted to get pump/CGM?

My insurance will cover pump, CGM, the works at 100%. Yippee you say! Me too, BUT I have a $5K Durable Medical Equipment annual cap on my insurance. Since the pump is over $5K by itself, all the infusion sets for the rest of the year (after using the 3-4 months worth that come with the pump i guess) will be out-of-pocket, as will (obviously) the CGM and whatever supplies THAT calls for.

I have heard through the grapevine that sometimes you can get your insurance co to lift that cap for the current year so that you can get all the stuff you need covered if you ask. AND I have considered asking our employer to lift it for us for this year as another approach.

Anyone tried anything like that with any success? Plan B of course is to wait until Aug or Sep to order a pump so that the next supplies will fall under the next insurance “year”.

Does that even make sense?


Very encouraging! Thanks Dave!

Try your drug coverage for supplies. My pump supplies, as well as my cgm sensors are covered under my drugs coverage. When I was looking at my cgm no one at my Dr believed that the sensors would be covered until I showed them my fomulary. I have A Blue Cross PPO with Medco drug coverage.

I have blue cross blue shield

I didn’t know they were in the formulary! Thanks a bunch for that information

they might not be, some are some are not, always helps to check.