I’ve seen it asked how the deal between United Healthcare and Medtronics, making Medtronics pumps “Preferred” and essentially exclusive, will play out regarding other related technologies, such as CGMs. Today, I think I found out - the hard way. I’ve been trying to get a new Dexcom transmitter and receiver ordered. After getting my prescriptions in order, I was informed that UHC is only allowing one new Dexcom receiver every 999 days, despite the 1-year warranty limitation on the device. So even though I’ve started having some problems with my out-of-warranty receiver, I will have to way another TWO YEARS before being able to get a new one through insurance!
To me, this is a clear indication that they want to force UHC members away from Dexcom and any vendor that isn’t Medtronics.
I feel your pain. UHC stopped covering me for any Dexcom products after covering me for 2and a half years. Just decided they wouldn’t cover me because I am on Medicare. I’ve been on Medicare for three years. I’m still,fighting that battle but not making much progress.
If you look at Medtronics behavior in broad context, there can’t be any serious doubt. Look, for example, at their marketing policies in third world countries. For better or worse, this is how they do business, consciously and with forethought.
UHC is also culpable regarding this preference for pumps. Maybe part of the issue isthat "1-year warranty limitation on the device". I prefer MM for my own pump, and the meter that links is not on the formulary for my insurance policy so my doc writes the strip rx to require that brand. UHC has an appeal process.
You can always find a new insurance that will offer all the coverage you require. If you are forced to subscribe to UHC then that is a whole nother shoe! Medicare is clear that they don’t cover CGMS for anyone, and fighting for coverage is always an option. There is a win in the books for a CGM being covered for a Medicare diabetic. All it takes is one!
Medtronic marketing policy behavior bashing is a smelly sock with holes all over it. Medtronic are in fact recognized by the WHO for their efforts in expanding global access to healthcare. Their products extend beyond diabetes.
I have held from day one this is about the sensor business, not the pump business. I believe that Medtronic is seeing improvements in the Dexcom devices thus calling a market switch. Especially since Dexcom has partnered with several pump companies to produce a unified device, thus erasing Medtronic’s single most significant marketing advantage.
We may be upset about the pump’s but again, in my opinion, its the sensor that is driving these decisions
Well, if a “smelly sock” equals export policies that withhold the technology absent a government-enforced monopoly, then yes. Otherwise, no. The paper trail is quite clear.
Did you have Dexcom navigate this for you? Dexcom is the one that should be all ballistic about this and working on the way to get approval. Do you have a representative in your area?
And my understanding is that once you are Medicare, it becomes your primary insurance and your private insurance becomes secondary. If your primary insurance concludes something is not covered that decision also filters down to secondary coverage. You secondary coverage will not step in and become primary coverage. You need to closely look at your secondary coverage. Some may contain a specific clause kicking in as primary coverage when Medicare denies, but often that is not the case. The whole coordination of benefits is a total morass intended to keep us as patients in the dark until it is too late and we are left holding the bills.
I’m not on Medicare. But yes, my doctor’s office told me to call a local Dexcom rep who is forwarding the issue to others at Dexcom. I am still waiting on a response, though I’m not sure what I’m expecting. The agent also told me of another case she’s working with regarding a patient that has a receiver and transmitter (out of warranty) that stopped working altogether. When they ordered new ones, UHC told them that they were “only allowed a new system every X years.” When they were told that the system was non-functional, UHC said they “would have to provide proof that the system was not working.”
The technician at Byram told me that the 1-in-999 days limitation on Dexcom receivers was a policy change from UHC that they were told in the past few days.
It seems to me that UHC has decided to treat Dexcom Receivers the same as insulin pumps, despite the fact that the device is not necessarily expected to function properly or warrantied for more than one year. As I said above, I am sure – as was the Dexcom rep I spoke with – that this is an effort to force people toward changing to a Medtronics system, due to the deal they made.
Hi! I fought Medicare for three years for CGM coverage. I am at the 5th step of Medicare Appeals process and unless you have $30,000. plus to go to Federal Court, no matter what the ALJ ruled, you lose! I am waiting on a request to re-open on one appeal. The best hope we have is to get HR1427 and S 804 onto the floor for votes in the House and Senate respectively. House has more than 50% co-sponsoring the their bill and Senate is almost at half. I pray that these are enacted to allow CGM coverage by Medicare.
That is really sad. Healthcare decisions shoud be between the patient and the doctor. The last I checked the House and Senate is mostly made-up of career politicians and lawyers.
I think your experience and that of the other patient you heard about is the unfortunate logical extension of the UHC/Medtronic agreement. Frankly I liked my Medtronic pumps just fine, I believe that their CGM is significantly inferior to those of Dexcom. It is possible that that the Enlite 3’s will narrow the gap, but after using Medtronic SofSensors, I would be terrified to abandon Dexcom. Also as someone who will be on Medicare in less than a year and might have to self-fund my CGM, I get at least 2 weeks from every sensor and I have not heard of many people who get this longevity from Medtronic sensors.
That being said, I do think that Medtronic does a fabulous job of combining pumps and CGM’s into a system.
I live a few miles from UHC’s headquarters and I think bad thoughts every time I drive by. Fortunately they are not my insurer and will never be if I have choice.
First and foremost, I am not on Medicare; however, I am on Medicaid and also using United Healthcare Community Plan - which I had to enroll in thru the “Marketplace.” (aka - Obamacare) I am not sure where to start b/c I can most certainly empathize with you, but I do not know which of the three are the lessor of three great evils!
Obamacare forces people to get or buy insurance when a) they might not need it; b) the insurance does not provide a service; or c) at a huge cost. UHC is the worst at paying pharmacies and doctors - which means ultimately the patient suffers. They instead of the doctors practically prescribe medication b/c they NEVER approve brand name drugs or any vitamins/minerals. (I was hospitalized back in Feb. 2016, was discharged & given a prescription for Potassium among other things. Ended up paying $8 a pill.) Now to get to Medtronics…their sales force and customer service reps are all sleazy used car salesmen!
Last year I was supposed to go onto an older Medtronics pump. (If you think UHC will approve the new version of any technology, please think again.) Anyhow, the pump never got to me and when I asked Anthony (the rep) to text and/or e-mail me the tracking number. He said I wouldn’t understand it! Two months later I received a call from a Medtronics supplier asking me where to send my insulin cartridges. Yes, Anthony lied, said I received the pump and it was attached to my body. Fast forward a month ago, not on a pump yet - but I have to b/c my A1C is 9 and I’ve been hospitalized twice in the last year. Had to try to go back to Medtronics. They called my cell phone & decided not to leave a message. Called them back and their rep told me I had a pump last year and decided to return it!?! He doesn’t know who called me or why and he can’t help me. Then he asked me: Didn’t you see a refund from the insurance company? (That is not how UHC works!) So now I had to call UHC to see if Medtronics actually refunded the money for a pump and supplies I never received. UHC had to send me to their fraud department b/c their customer service rep didn’t know what I was talking about.
Adding insult to injury. The Endocrinologist told me to use Dexcom b/c of accuracy concerns. I still don’t know how this will play out with UHC, but the other insurance options in the “marketplace” are not much better.
Follow-up. At my doctor’s office request, I contacted a local Dexcom rep who investigated the situation for me. They discovered that the 999-day rule has been around for a while, but that until now, UHC was not enforcing it (which has apparently now changed). She sent me a form for my doctor to complete that indicates a request for a replacement receiver for one that is malfunctioning out of warranty. The doctor sent in the form, and I received a letter from UHC approving a new receiver (though they gave me a very short window in which to get it). The new receiver has now been ordered.
My company insurance is switching to UHC in January and they will not cover my OmniPod after 12 months. They are only covering Medtronic pumps. My coverage went from 100% to 0% overnight. I spoke to the HR here and they offered very little help.
Phoning Insulet directly may provide some assistance, as all of the pump/CGM companies have people who can pretty much drill down into your insurance coverage and talk directly with them on your behalf. Worth a try.
UHC listed 3 exceptions to their Medtronics policy:
There are exceptions for the following reasons: 1. Member is under the age of 18, or 2. Member is Medicare Primary, or 3. Member obtains a clinical exception
My HR told me to begin on #3 sometime next year. I have observed my best ever A1c since being on the Omnipod, so I"m planning on leveraging that information with the help of my endo.
As far as how much help Insulet will give you, it really depends on who you are working with. Some will fight for you, and some will just go for easier low-hanging fruit. People with BCBS or Cigna are easier for the Insulet rep to close the sale, so they don’t want to “waste” too much time on UHC patients. Totally depends on who you are working with.
I got help from my local Insulet rep, she did her best. But after fighting with UCH and documenting all that I had to do, I offered the details to the Insulet District Sales Manager who is above her. She had no interest in learning anything about how to fight UHC. I think she is just interested in the low-hanging fruit, and fighting UHC wasn’t worth her trouble.
Insulet loses so many UHC appeals, they don’t really dig in to the fight. It’s a matter of perspective. As diabetics, WE are fighting for our life, but THEY are fighting for their lunch.
Anthony,
I fought UHC and it took me a long time to win. Message me sometime and we can arrange a call and I can tell you some things that might help. There are a lot of things at play, and it depends on the route you want to go to try and win. Let’s talk sometime.
