Insurance Company criteria for replacing Insulin Pumps

Can anyone comment on the criteria health insurance companies use in
approving a replacement insurance pump? I’ve had mine for about 5
years and it is currently out of warranty. It was paid for in full by
my current health insurance provider. What criteria do insurance
companies use to approve a replacement or upgrade? Is it strictly
based upon need say my pump failed? What are your experiences in this

As my pump is about 5 years old I worry that I will find myself going
through the process of getting another while going back to the needle
while an replacement is worked out. I would feel a whole lot better
about things if the model I have presently could be used as a backup.

What reasons will an insurance company typically accept as acceptable
in making a replacement outside of the pump’s failure?

I would like comments on the current trend of health insurance
providers reducing benefits in this area to say covering 50% of pump
costs. I am facing the prospect of having to change my insurance
coverage and find the plans I must now consider are far less generous
in what they cover.

Hello William!

My insurance co will cover a new pump every 5 years, all but about $700, which I am responsible for. It varies so much that I am afraid your answer is neither easy nor straight forward. Try to work with the pump manufacturers, they will know what the terms are based on what policy you have, for example, only my MM rep knew that Horizon BCBS in New Jersey will now cover CGM. best of luck to you and may the gremlins stay out of your pump!

I’m on my 3rd pump now, and both times my endo brought it up around 4-5 years. He got the ball rolling with a new prescription for it, and the insurance never questioned it. Also, I didn’t have to pay a copay when I traded in my old pump.

My insurance was willing to replace my pump once the warranty was up (4 years), and paid 80%. I also was able to trade in my old pump to offset a little of the 20% portion that I was responsible for paying. I agree with Joe that you should allow the pump company of your choice to help you navigate the insurance. They are better at it than we are.

my experience has been when the warranty is up, they will cover—at whatever level of Durable Medical Goods you have. In the past it was always 100% - now i am at 90%.

Just so you know. I had a pump break right after the 4 year warrenty ended. I called the pump company and they sent a new one the next day on terms that I buy another from them. So if you want to switch brands letting it break is not the way to go.