[IP] CGMS Coverage -- SUCCESS!
My shiny new CGMS came today and I was very pleased to find out over
the holidays that my prescription plan is covering the kit and the
sensors! My insurance plan (with Aetna) denied it (as I expected), so
MM checked my prescription plan (with Caremark) instead (unexpected).
The upgrade kit will cost me a double co-pay and the sensors will be
the normal 3-month supply co-pay. I do have exceptionally good
prescription coverage, so for me, this is even much better than
insurance coverage with Aetna would have been. It sounds like in the
future I might also be able to get pump supplies through my
prescription plan as well, which should save me a tiny bit of $ too
(not nearly as much though). MM told me that insurance/prescription
plans are now re-evaluating how disposables for durable medical
equipment are being treated.
Like you, I also have Aetna Insurance with Caremark Prescription
coverage. Unlike you, for prescription coverage, my company switched
from co-pays to co-insurance a few years ago to save money. This
turned the $20 Caremark co-pay into a 20% patient contribution towards
prescription coverage. This means I most likely will have a "steel
cage match" with Aetna to get CGMS coverage, since Caremark
prescription coverage would be more expensive than Aetna coverage. I
anticipate several rounds of appeals.
On the positive side, if I win the match with Aetna, I think they
would pay for it under DME coverage and there should be no co-pay or
co-insurance, just like my insulin pump supplies. My 20% co-insurance
with Caremark also has a $750 maximum patient contribution. Your
success lets me know that if Aetna prevails, I may have a secondary
option with Caremark and in effect it would cost me a maximum of $750
per year for CGMS coverage.
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