Insurance only covers 50% of cgm and pump

I am in the process of trying to get a pump and cgm. My insurance (aetna) is telling me they only cover 50% of the cost after my $1000 deductible is met. That means I’m going to be on the hook for almost $350 a month for all my diabetic supplies. Does this sound right?? I have the highest, most expensive plan my company offers. I pay nearly $800 a month for insurance for my husband and I. How could my coverage for this be so minimal? Is there any company I can contact to assist with the cost? I am considering going on the NYS healthcare marketplace to find better coverage. Is there a specific plan that would cover this stuff? I am just devastated over this. I am pregnant and been having to prick my finger On average 15X a day and inject at least 5X a day, and have been having terrible overnight lows. I was so looking forward to getting on a cgm and pump. Any and all advice is appreciated. Thank you.

@Emilyrogers92417 Hi Emily,

It’s hard to say what sounds right. The pump, considered DME by most insurance companies, lists for over $8,000 but is usually negotiated very much lower by the insurance company, who then sticks you with 1000 and then you pay apparently 50% of what’s left… if the negotiated price is lower, your coinsurance may have less impact.

the DME deductible “sounds” about right to me… mine is 1000, plus 3000 or some absolutely mind-numbing calculation for in and out network doctors… my pharmacy plan pays for my testing supplies as well as insulin and infusion systems.

my opinion: Make your preferred pump representative give you a real number for your out of pocket, and try to negotiate. same-same for the CGM company if it’s DEX and not offered with the pump such as Medtronic.

Pumping is the most expensive therapy, but I’ve found it to be very useful. Good luck and best wishes for you and your baby and congratulations

Hello Emily and congratulations! I am rather new to this, as my daughter was just diagnosed in October, but I spent a few months researching insurance, as our old marketplace plan had very poor coverage for supplies and zero for a cgm. We are self-employed, so we need to go through the marketplace. I found the plans in PA vary greatly with what they provide, with Blue Cross being the poorest and UPMC being better. The very best, and most expensive plan covers 50% of a cgm or pump, but has good prescription benefits. I was also advised to contact Dexcom directly to check for assistance or coupons. For now, my daughter has qualified for Medicaid in PA with the Type 1 diagnosis, but I wonder what will happen after she turns 18. Best wishes to you…

Recognize this reply is many months since your inquiry, but hope it is helpful anyway. JDRF lists some resources for lowering costs here: Help with Your Diabetes Prescription and Insulin Costs - JDRF Likewise, let the pump/CGM provider do some work for you by checking whether supplies are covered under the plan’s pharmacy policy. Dexcom and Freestyle Libre, for example, are often covered under a pharmacy plan because they can largely replace glucose test strips; Medtronic’s CGM, however, requires 2–3x per day calibration, so doesn’t have nearly the same reduction in glucose test strip use. Likewise, OneDrop offers very economical options compared to OneTouch, Contour, etc. — including unlimited glucose test strips. Finally, after analyzing total annual costs for insulin, CGM, glucose test strips, pump supplies, etc. for T1D coverage, my household found that it can be more economical to pay higher premium for lower deductibles and copays.

Switch to Cigna, they have a great Diabetic program, Insulin is $9.00 a bottle and my CGM for first month including transmitters and PDM is 102.00 after that it is approx. 50 a month. Keep me posted Jan