I’m on the insulin pens and do manual blood sugar testing. I’m getting insurance through my school and I’m so confused on where go start and need some guidance. I know I wanna get an insulin pump and CGM but how do I approach this? I will have united healthcare. Are there certain types of insulin pumps that work better? Does my doctor have to prescribe insulin pump/CGM? How much should I expect to copay for insulin pump/CGM? What should I look out for in terms of my insurance trying to trick me? Thank you guys so much in advance
Everything you get will need a doctor’s prescription.
Important insurance terms-
Premium - amount you pay monthly to have the insurance.
Deductible - Amount of money you must pay out of pocket before insurance starts paying.
Copay - The amount you pay for prescriptions or services. After your deductible is met you will pay a fixed amount, i.e. $5-$30 or 20% for a bottle of insulin or a doctors visit.
Out of Pocket Max - the maximum amount you will need to pay in a year before the insurance company will cover 100% of the costs of all goods and services.
First you need to see a Primary Care Physician and Endocrinologist. Your insurance company will have a website that you can log into. There should be an electronic copy of your ID Card if you ever need it, a break down of the insurance term, conditions, and rates. The website will provide you a function to search for doctors in your area that are “In Network” or accept your insurance. The insurance website should also provide you with receipts and breakdowns of all the claims youve filed with them, and there should also be a list of “Preferred Formularies”, which is the drug manufacturers your insurance prefers. Sometimes they will only cover a certain brand of insulin or test strips.
Make sure you throughly read reviews for a doctor before you pick one. At least half of doctors and Endocrinologists are terrible about answering phone calls or responding to voice mails. I wouldnt recommended doctors or Endos that have more than one location they practice(they work in different offices on different days), because getting them to sign a form or respond to the pharmacy is like pulling teeth.
Ask the Endocrinologist about insulin pumps. They can get you in touch with a manufacturer. For me, I saw my first Endocrinologist this January after 15 years with Type 1. He recommended a pump, the 670g, and put me in contact with a Medtronic sales rep. They pushed all the paperwork through my insurance company and figured out exactly what my monthly costs would be, and offered awesome payment plans on the cost of the pump that was my copay.
With insurance, remember that everybody involved is making money except for you. The pharmacy, the doctor, the pharmaceutical company, and the insulin pump manufacturer all want to sell you something and would love for your insurance company to write them a big, fat check for it. Theyre also experts at dealing with insurance companies. If you ever have any problems with insurance “trying to trick you”, call one of these entities that is making money and they will help you.
I currently have wierd insurance, they pay 100% before deductible for my insulin, test strips, and syringes. But my deductible is somewhat high at $1300, and copay not great at 20% for prescriptions and doctor visits. I got the 670g from Medtronic in February, and I think the 670g pump is probably one of the most expensive pumps on the market at $12,000 for the pump, CGM, and first 3 months supplies. I paid $2,400 of that, insurance paid the rest. The manufacturer offers interest free payment plans up to 4 years. Im paying it off at $200 a month for 12 months, but I could of stretched it out to $50 a month for 4 years. With my 20% copay, my CGM sensors, reservoirs, and infusion sets are roughly $100 a month. They gave me a training class on how to set up and us the pump, plus the trainer keeps in contact to see how I am doing.
Dont be afraid to reach out to companies and ask questions, it costs nothing other than your time. You can ask your insurance for advice, your doctor, or any pump manufacturer. As a diabetic, the insurance company is probably going to lose money on you. Most people with insurance never use it. But, if you dont take care of yourself and end up sick or in the hospital, the insurance company will lose a LOT more money. A single DKA episode that puts you into the hospital will easily cost as much for the insurance company as an insulin pump. So, it IS in the insurance company’s best interest to keep you healthy. They want you to stay healthy in the long run, and the pharmaceuticals want to rake your insurance company over the coals for every penny they have. You really do have several multibillion dollar companies willing to fight each other for you, all you need to to is find the right ones to talk to when you have a question or problem.
Hi Nawal @wallie and Welcome to the TypeOneNation Forum!
I’ll offer some thought on your several questions. Yes, both insulin pumps and continuous monitoring devices / systems require a doctor’s prescription. It will be decided between both you and a doctor, preferably an endocrinologist, when and IF you need either of those devices A pump is not the “best” solution for all people with T1D and the prescribing doctor needs to certify that in her/his estimation that you are motivated to use the CGM effectively. Using a pump and CGM is NOT a “plug-n-go” solution for effective diabetes management - these devices often require the person with diabetes to work harder.
Under most insurance pumps [Insulet OmniPod is an exception] and CGM hardware require a durable equipment [DME] co-pay identified in the plan - usually 20%. The major cost in using these devices is the on-going supply fees for infusion sets, reservoirs/cartridges, sensors, transmitters, etc.; check to see how much you will be paying on a monthly/quarterly basis. Your doctor will periodically be required to certify that you are using the “stuff” effectively for insurance to continue paying.
There is much discussion already posted on this forum with opinions of “best” pump and CGM; use the magnifying glass search button at the top of this page to search for those strings. The most popular brands of these devices in the USA are: DexCom, Abbott, Medtronic, Tandem, Insulet; do YOUR research on what you need before talking with your doctor. Be proactive and keep yourself informed.
Hi there. Since you’re considering pumps you might check to see if your insurance carrier includes /excludes certain ones - sometimes companies have preferences about which medication or product they will cover. Once you know your options your endo may be able to navigate trying a loaner. I was curious about the Omnipod a few years ago and they sent me a sample to try out. You can’t actually use it but you can get a feel for wearing it. I’ve been pumping for years and things may have changed, but when I first tried the Minimed they had me practice with one using sterile saline so I could get a feel for how to use it. At the time I believe I had the option to send it back is I decided against it. That may have changed. A few years ago I switched from Minimed to the TSlim, mainly because I liked the sleeker look of it. Both functioned equally well for me. Anyway, there are some options out there. Diabetes forecast.org ''s 2018 consumer guide has a comparative chart for pumps, meters and other supplies.