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Re: [IP] CGMS Coverage -- SUCCESS!

When you say Caremark are you referring to this?:


--- On Sat, 1/3/09, Ricardo <email @ redacted> wrote:
From: Ricardo <email @ redacted>
Subject: [IP] CGMS Coverage -- SUCCESS!
To: email @ redacted
Date: Saturday, January 3, 2009, 7:12 AM

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
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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