Keystone HMO Proactive (PA) approved my Dexcom at my DME benefit of 50% and will cover the monthly shipment of sensors at the same 50%. The Dexcom rep that processed my claim said to me that my insurance company will approve both T1 and T2 with just a Certificate of Medical Necessity.
I had to support the need when first approved as a med device under both insurances - dr wrote that that I had hypo unawareness but did not have any hospitalizations. It probably helped that I was a type 1 with an A1c of between 10 to 11 for the past 8 years. As a prescription nothing was needed except a prescription
I am on Medicare through Humana. I got Humana to pay for my Dexcom System in January 2013, but last month someone reviewed Medicare's guidelines covering CGM and found out that Medicare doesn't cover CGM so I am on my own now. Thank you very much Medicare for caring for the seniors with diabetes, not.
Greetings,
I am a type 1 Diabetic who has been dealing with the challenge for 18 years now. My entire life as a type 1 I have never been below an A1C of 8.5. I have been struggling to get a G4 since I read about them and my DCP started the process for me. I have BCBS PPO through my employer and DME/Medical is at $5000 deductible. I work as a Network Administrator for a small to mid-sized wastewater company and infection is always a concern due to the lack of sanitation in some of their operations offices that I work in on a daily basis. Staph and MRSA scares, hepatitis, etc, some of the locations do not even have clean running water. So to make a long story short, the G4 or any type of CGM that would allow me to better monitor my blood glucose readings without needing to risk infection would change my life; however, it appears that due to the way BCBS/Express Scripts codes the G4 sensors/transmittors, they will not run them through prescription coverage so it can be affordable.
I completely understand if they run the machine itself through DME/Medical, but to run the monthly supplies through DME instead of prescription coverage is rediculous. I already pay nearly 200/mo for my monthly insulin and testing strips. Which doesn't include the other necessities like cholesterol meds, etc. I have been going back and forth with the insurance company and Dexcom for the past 9 months. I have had my Endo submit several Letters of Medical necessity, being lead to believe that doing so would be successful. Unfortunately, both attempts to send the letters in for processing and peer review after 8 months were all for not. I would wait several months, call the insurance company, to be told they had no record of the letters. One time I had called for the first medical necessity letter to see it's progress and was told that they had confirmation of receiving the letter but would not discuss anything and I mean anything with me because I wasn't a medical professional/provider. So I am starting again but through Dexcom directly this time. We will see where it leads but I am beginning to think I am practicing the definition of insanity.
Real sorry to hear of your travails, Lucas. A $5k ded. on DME sounds really high, high enough where your $5000 would like be soaked up buying the Rx, the Tx and sensors for a years' time though, right? Thus, you basically would get no help from your insurance even if everything was charged to you as DME. Or am I misinterpreting what you wrote? Do you NOT have to pay $5000 out of pocket (as your DME ded.) before your Ins company pays anything? That's how I read it.
When Dexcom and Medtronics approached the FDA about getting approval for their CGM systems some time ago, they did so knowing that the Rx and Tx are definitely DME (items that can be used by anyone, the very definition of durable medical equipment), but that the sensors are not, strictly speaking, DME. However, those two companies and the FDA found that it would be less intrusive and complicated to the gen pop as a whole to have everything covered as DME. Slicing up things for these types of complicated 'systems' between DME and prescription was seen as too difficult on the consumer as well as on the OEMs.
All of the above info came out of several discussions I had with Dexcom last year in regards to my own issues I had with Solara (Cigna's billing arm) when they decided that the Dexcom sensors should be prescription (something I most definitely did NOT want as my DME was covered at 100% with no deductible last year -- the polar opposite of your situation, I know). In the end, they realized their mistake -- that ALL of the Dexcom system is DME -- so they credited me the $974 they charged me for 90 days worth of sensors. Dexcom's contracts with vendors states that all of their system is DME.
Hopefully this helps explain a little bit about the why of things a bit.
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Lucas with the use of the Dexcom G4, insulin pens, good eating habits and counting carbs and responding to highs and lows immediately I have total control of my diabetes and always come in between 5.2 and 5.6 AIC's. My Endo is amazed when I take my Glucose charts to her. I will always have the Dexcom system as long as the made it even if I am reduced to selling pop cans, lol.
Good Luck,
Bob
Thanks for the reply and information from your own personal search. My insurance will not cover a dime until I reach $5000 out of pocket for DME. Which is why I have been desperately trying to get the sensors to process through prescription benefits where I only pay a copay per script after spending $250.00 out of pocket. At $304.00 per month for sensors + what I already pay in copays for my scripts, (humalog, lantus, strips, cholesterol meds, etc) I would be at around $550-$600. When you factor in other bills, rent, cost of insurance, etc... it just doesn't fit. My only other hope is to try and use my wife's insurance as supplemental or drop my employers insurance all together and look for a different plan. It's unfortunate that ruling things for the general population are just gathering us up and throwing us into a very broad box. Exceptions should be able to be made based on medical necessity and doctor approval.
Thanks for sharing your experience Bob. I hope I can meet the same result, I have been waiting my entire life as a diabetic for a technology like this. One or two outcomes will happen, I will either change jobs after dedicating 10 years to this company for an environment more suited to my profession and more sanitary where I can do it with many test strips and mini-doses or find an affordable solution to obtain the G4.
I agree whole-heartedly with Bob Martin about the life changing results from the G4. I am blessed to have remarkable coverage at 100% for both the Dexcom system, sensors and Omnipod pumps and my last A1C was 6.1. At the same time, I wear my sensors for on average at least 3 weeks at a time, usually 4 weeks. I would pay for it out of pocket if I had to but would only get 1 box of sensors at a time. My current one is perched on the back of my arm and is on day 24 with no loss of accuracy. It's a lot more affordable at $100 a month for sensors, rather than $ 100 a week. But worth every penny imo.
I disagree with your final point Lucas, but I think that is because our insurance plans are so very different. I think CGM 'systems' should stay under DME, as it was approved of by the FDA, and how Dexcom's contracts are written with suppliers. It is simple across the board to maintain a 'system' under one type of plan, and since 2/3s of CGM systems are clearly DME, it just makes sense to keep it all that way under DME.
Where you get caught out is in that astronomical deductible!
I think your insurance company should alter its plan to lower DME costs to its members (again, $5k ded. seems really high to me!), and then keep it all under DME. I was super lucky last year to have 100% coverage with no deductible, but things are not so rosy for me this year. While I am not at a $5k ded. like you, mine is certainly higher than paying nothing, which is where I was at last year. As a result, I am currently using sensors for as long as I can, and using them well past their use-by dates (I'm currently using sensors that expired in April, oh well... still working fine according to my calibration blood tests). So, maybe put some pressure on your insurance folks to bring your deductible down. I don't know if you'll have much luck going the route of trying to dissect the approved CGM DME 'systems' we've been talking about (but, maybe you will get lucky?!?!!).
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My insurance - Blue Shield of California - is covering it 100%. Thank God!
am now trying for the Omnipod which is also covered 100%Unfortunately, I found that my company switched from a decent coverage plan to a catastrophic plan to save on premiums which is all good and fine for healthy people but not so good for people like me. So, to make a long story short they'd rather see me in the ER or struggle with old tech instead of moving forward with new tech and improving life. I am not going to mope around about it though, this job isn't forever and I have plenty of opportunities in the future for better jobs and better insurance coverage. I have enough discipline to lock it down and try to figure out ways around the poor sanitation in my current working environment. If they have an issue with it, they will either deal with it or replace me. ;) It's time to mush on and make myself a better future.
After meeting my deductible, they are supposed to pay 80%. Getting to that point is painful. I'm glad the insurance reduces the price, and still it doesn't take much time to reach my deductible because of the high prices. God help me if I didn't have insurance... $2300 or so for 90 days of sensors? Not to mention the replacement transmitters and receivers! I think they shortened the battery life on the G4 transmitters to make up for the lost revenue from us who reuse sensors. Aw, poor, deprived Dexcom.
I changed insurance from Oxford to Aetna January 2014. Before changing insurance, I confirmed that Aetna covered Dexcom.
In May, I ordered sensors. Edgepark first got pre-approval from Aetna, then shipped me. Aetna accepted the claim, reduced my deductible and paid Edgepark. After 3 weeks, Aetna sent me a letter saying they are denying the claim. That the device is "Experimental". Meanwhile I had to order a new transmitter. Aetna accepted and paid for it. they did not call it "Experimental".
So, the transmitter is not "Experimental", But the sensors are? And that after having pre-approved and accepted it?
Aetna is a nightmare.
It's so confusing to them (even though this is their job!) because two parts of the trio that make up CGM systems are DME through and through: the Tx and the Rx can be used multiple times (here's the SS definition: https://secure.ssa.gov/poms.nsf/lnx/0600610200), which by definition makes them DME. But, the sensors? Not so much -- as we all know, we use them once and they die. So, they are not DME because you can't use them multiple times like you can the Tx and Rx, right?
Not so fast: when Dexcom and Medtronics approached the FDA (they did so together according to the folks I spoke with at Dexcom about this very subject a year ago), it was agreed upon by all parties that ALL portions of CGM systems would be deemed DME to cut down on confusion and mis-billing and such. And still they are confused!
There was another thread here recently where a member was trying to get his insurance company to see the sensors as prescription meds rather than DME (he had a very high DME deductible as I recall it), but the way that Dexcom and Medtronics worked the deal with the govt strictly forbids this: all portions of CGM systems are DME. That's it. It is clear and simple, and should be easy to administrate, but for some reason the simplicity of this setup eludes some of the paper pushers at companies like Aetna.
And it doesn't help when someone whose insurance company charges a high deductible then muddies the waters by asking for the sensors to be seen as prescription meds. Of course, on the face of it, this makes sense since the sensors are clearly NOT DME if you look at them by themselves, however they are 1/3 of a system that has been defined wholly as DME by the manufacturers and the govt together.
Hope you get it sorted.
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Yes my Dexcome G4 sensors are covered by RegenceBS of Illinois as a Rx. Dexcom refered me to Foundation Care, a mail order pharmacy, who would bill my insurance as a Rx code. I currently pay a $10 Rx copay for a 1 month supply which they allow 2bxs/mo, which is plenty for 2 months or more so my copay is less than $5/mo if I go more than 7days/sensor.
But to my dismay I have to go on Medicare and will loose this policy. I'm excluded from continuing it because I am now Medicare eligible.
Dexcom has been no help and I've spent many hours trying to find a policy.
Humana does list the sensors under a Rx code but will not cover them, so
I'm giving up and will just have to live not being able to handle my Bg's the best way possible.
I have the State of Texas Medicare Advantage plan by Humana. This is a retirement plan which Humana says is very good. I am Type 2 and was just told by Dexcom that the CGM is covered 100% after prior approval. I have been fighting BG ranging from the 90's to 250+ for the past few months. My A1C went from 6.4 to 7.5 in three months. Part has been illness and the rest unexplained.
Steve
A similar thing happen to me with my Medicare Humana Advantage Plan. Humana first approved the Dexcom G4 through their Prescription Program and 18 months later stop covering it using Medicare as the excuse for denying me this valuable tool. The reason given was that the equipment was not cover under Part B, duh. I have been waiting on my denial letter, but I haven't receive one to date. I plan to call and demand a denial letter so I can appeal their decision not to cover the Dexcom.
I'm finally getting mine this week. I have to pay 20% after deductible is met. Also same for the sensors. I did have to send in logs, but have had no hospitalizations due to low or highs. But I used to have the guardian from minimed, so everyone already knows I can't always tell when I'm low. my insurance is BCBS