Need Tips on Getting Coverage for Dexcom Sensors w/ United Healthcare

They approved usage but at Tier 3 - high copay and % of cost. My pods were also approved (not on formulary, but covered under durable equipment benefit…no cost since I have met the deductible. Has anyone had different experience - what works to get it covered under durable equipment? So ironic that they are willing to buy me a new pump (Medtronic) so I can use the Enlite sensors. Don’t want to go back to tubed pump :frowning:

I have United Healthcare and have (had) both those covered; however, my plan is (obviously) different. Under my plan, there’s a separate $1500 copay on DME - aside from the regular $1500 medical copay. After the copay, my cost is 20%. When the formulary changed last July, UHC decided that all Dexcom products would be covered as pharmacy, rather than DME; however, I was told that was only for Type 1, for Type 2, it would still be DME - this would have cost me quite a bit more, annually. In addition, the approval process for DME is different than the pharmacy approval process. So even though I was approved for CGM from pharmacy, medical/DME rejected me…

To make a long story longer, it took a lot of work on the part of my company’s benefits administrator, a VP of sales and my boss to get the coverage straightened out. In the end, I get my Dexcom covered (yes, Tier 3) via pharmacy as well as my pump supplies. Omnipod was at Tier 3, though, now I’m on the Animas Vibe (tubed) and the supplies are Tier 2.

… until July 1 when the formulary changes and the fun begins anew! :dizzy_face: :dizzy:

1 Like

Thanks Thas :slight_smile: I am somewhat lucky in that my deductable is $800 total (combined pharmacy and durable equipment) but at Tier 3 or 4 I pay a huge copay (mandatory). The key is to be on formulary and Tier 1 (Humalog vs Novolog) or 2 ($35 copay)…above that, cost increases greatly…$140 copay minimum + 20% co-insurance (pumps and evidently Dexcom supplies); $300 copay minimum + 30% co-insurance…and that is every month regardless of meeting the deductible. I am not sure what they do when I hit the out of pocket max. It should be free after that - but maybe they have redefined “max.” :dizzy_face: My out of pocket max is $2,250…and somehow they say I only have a little over $1k left to meet it.

I can’t believe they change the formulary mid-year!! I was told that Cigna changed from Novolog to Humalog and then back again. I think they are trying to kill us all…just kidding :wink:

Tell me about it! I keep getting told I have to switch to Humalog - even though I have an allergy to it… Have to fight that at least once a year, sometimes twice. Thankfully my plan has a simple pharmacy copay structure of Tier 1/2/3 at $10/35/60, though they complicate that by forcing me to get some meds (like the Apidra or Novolog that I can use and need) via the mail from OptumRx. Even though it saves a little on the copays, I’d rather be able to go to the local pharmacy.

1 Like

Patricia5, you got it right the first time: health insurers ARE trying to kill us (at least we insureds who ruin their profit margin!)… :rage:

1 Like

Well, the saga continued this week - eating up about 10 hrs of my time calling, being on hold, etc. Now I am told, by United, that there is a code for Dexom sensors under DME benefit. They would not let me link to that info. After calls to Dexcom, Solara (3rd party approved provider), some other crazy 3rd party pharmacy provider…still not sure who can provide my supplies as “in network” and as a DME benefit. Monday I start in again. I purchased a notebook to just keep notes from my healthcare communications. How are we supposed to be able to work AND ensure we get healthcare :wink: snarky face.

If you do decide to go back to a tubed pump, the Animas Vibe uses Dexcom sensors, which I believe are the most accurate. We did fight United years ago. You have to fight. It took more than one appeal. Basically, I downloaded cgms studies from children with diabetes websites and perhaps even tudiabetes websites and printed them out. Then we had to prove individual necessity. We downloaded a month’s worth of data from her meter which we always have had fifties, and the month we downloaded, we had two 35s. We were at Naomi Berrie Diabetes Center and their pediatric endo department will support you and fight for you. We had a nurse from the insurance company helping us as well. The second appeal, they assign a Nurse/Manager to oversee the process. She was sympathetic, even though she did work for the insurance company. I don’t remember if we got it under durable medical equipment; perhaps the receiver and dexcom was durable and the refills were not? Although she was approved, DD no longer wants to wear the dexcom. I don’t know why they are making it so difficult to cover Dex and Omnipod. It is actually a lot more expensive to use Minimed with Enlites or Animas Vibe. Omnipod is relatively inexpensive compared to the upfront costs of the other pumps.

As a f/u a year or so later…I got coverage for my supplies and now have Cigna :wink: I’m looking forward to the closed loop pump coming out from Insulet/Dexcom. Anyone hear anymore about how the rollout will begin? Looks like Insulet will have a new pump pod w/ WIFI that will work w/ the Dexcom sensors (probably another upgrade - G6). Any word on faster, more concentrated insulins?

I don’t know how much you have read over the last few years about Pod failures, but I have and it is but one factor (a big one) for me never to seriously consider Omnipod over my MM pump. I’m not happy with all of the issues that Enlite sensors have (I used them for over a year) and I’m not thrilled with the prospect of a product coming from Insulet that has such a similarly poor track record (failure rate). Therefore I’ll stick with the tried and true, a MM pump and Dexcom sensors despite that combo of hardware not being a so-called closed loop system such as you are anticipating from Insulet/Dexcom. It’s a shame that MM and Dexcom couldn’t be partners but that will never happen thanks to MM’s foray into the sensor business–a business I wish they never entered.

And please, no “hate mail” from Pod users, as I’m only referring to the many, many reports of failures. That’s not something you read about with MM pumps, and since I’ve been using their pumps since 1996 and have had just two hard failures (besides 2 pumps; one that ended up being dropped on concrete and one dunked in Mission Bay when I overturned a jet ski) I feel super confident in the continued use of my MM pump. I don’t know a thing about their latest pumps, however. I’m using a 551