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[IP] CGMS Coverage -- SUCCESS!



Sarah Wrote:
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.

Ricardo Responds:
Congratulations Sarah,

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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