Medtronic sensors and insurance


#1

Can anyone please tell me if their guardian sensor three it is covered by a pharmacy benefit? I have been having a horrible time trying to figure this out spending hours on the phone with Insurance and device companies. When I was using a Dexcom the sensors were covered under Pharmacy and now the medtronic is not. Is it true that medtronic will not contract with distributors using the pharmacy benefit? Thank you so much I am feeling very frustrated.


#2

It’s been awhile since I used the original medtronic Sof-sensors, but they were always covered as DME, not pharmacy. Probably because typically reservoirs and infusions sets also needed to be supplied. A sensor that can only be read by the pump would make sense to be handled the same as pump supplies.

I switched to dexcom, which did not integrate with pump (minimed). And with one plan, this was covered under pharmacy. But now even that must be DME in my current plan.

If you have employer insurance, contact, HR to see if they can help determine if any of plans offered would do this.
Some employers get specific exceptions written into agreements with providers.


#3

I am going through the same issue.
Medtronic sensors ARE a pharmacy benefit.
You may need to get a Prior Authorization approved. The doctors office and P.A. Dept of the insurance company handle that. Many dr offices don’t know that the sensors are pharmacy (prescription) benefits, so you have to make sure they understand that you do NOT want to use your DME benefits.
I set up the prior authorization with Optumrx, then was told their mail order pharmacy could not get them at all. I’m a pharmacist and I knew that wasn’t true. They may have to special order them or have them “Drop shipped”.
No one in any department at Optum rx could tell me what DME/specialty PHARMACIES they contracted with. I spent HOURS on the phone.
Finally another pharmacist found out that the Gaussian sensors were not in their system at all or not coded correctly in their system. She is going to get back to me in a few days and we are pretty sure they will have the ability to supply the sensors very soon.
In the mean time, I found a local independent pharmacy that can order them and fill the prescription for a one month supply at a time.
Even then someone called me back and said they couldn’t get them in stock. I had to tell that person that they could get them by calling their wholesaler and requesting to have them “dropped shipped” …
Had I not known the lingo and process, I would not have gotten anywhere.
I am going to keep pushing the issue with OptumRx mail order and hopefully in a couple weeks they will be able to supply guardian sensor.


#4

Laura, thank you so much for your reply. I feel like I have someone who can relate to this huge struggle! So much time on hold taking to people who have no idea what they are talking about until eventually we are told nothing can be done. I am actually beginning my return process for the 670 pump because it will cost me an additional 1700 per year because of this sensor not being covered by pharmacy benefit. Which is so frustrating because my insurance DOES cover it but no one will supply it. You have given me pause now. Maybe I will try a local pharmacy… Optum Rx has told me they will override since I was directed to get sensor from Medtronic directly. Problem is Medtronic will not do it this way. Please update me if you have any progress. I really like the 670 but if Dexcom is covered better I will just sit tight until something else materializes.


#5

Last I checked (about a month ago), Medicare was not covering Guardian 3 sensors. In 2017, my United Healthcare supplemental covered 80%. In 2018, my insurance was switched to United Healthcare Group Medicare, which currently does not cover the sensors.


#6

OptumRx mail order pharmacy can NOW fill prescriptions for Guardian 3 Sensors. !!!
You need a 3 month supply prescription sent to OptumRx.
The sensors ARE a “pharmacy covered benefit” so you do not not to go through the medical portion of your insurance and meet deductibles and pay a percentage.
It’s still expensive, but less expensive per year that meeting deductibles and paying %


#7

Thank you so much. I seriously just printed out return labels for this pump. But I am currently on hold with Optum and they are still telling me they cannot do it. Is there any hints you can tell me to tell them???


#8

Ok! Update! I think it will go through with Optum Rx. I am so afraid to get excited since this has been such a giant pain in the you know what. I wish I loved the 670 more… it is certainly not perfect but I guess I am keeping it. If only there was some better options out there! Thanks for all the input.