Hello! I recently married a wonderful man 6 months ago, who was diagnosed with T1D 8 years ago, and Is now hoping to Try CGMs. Since we are about to enter open enrollment, we wanted to see if anyone here has an insurance provider they can recommend which has covered the Dexcom G6 without too many denials and appeals? I have heard BlueCross Blue Shield is pretty good with CGM coverage.
@ennieves, Erica, first welcome to T1N. You are correct BCBS has pretty good CGM coverage from my perspective. I am on Medicare + BCBS from an employer.
There are several points with BCBS. There are different coverage levels depending on locality and employer. So, a blanket “go with BCBS” is not prudent.
If you feel comfortable sharing your state and employment sector like small private, multinational, local/state government, or US Gov’t may give another here sufficient info to provide a better answer.
Please share what you find out. It helps all of us here learn.
@ennieves Hi Erica, and welcome to the JDRF TypeOneNation Forum!
I suggest that you research all insurance options available to you, and your “wonderful man”; congratulations on your very recent marriage, and may the two of you have many wonderful years together. As @987jaj said, insurance policies vary from location to location, including coverage and “exceptions” in BC/BS policies.
CGM is only one of the many things to look at. I suggest that you construct a simple spreadsheet, start with a column listing ALL medical expected expenditures, and in subsequent columns put what your actual out-of-pocket will be under specific policies.
I am trying to decide this week as well. We use Kaiser for my husband and I and for our daughter we go with Moda (private, no employer) and may stay with it for 2021. Last year with Moda Silver Beacon network it was about $324/month going up a few dollars for 2021, $3500 deducitble, supplies are through Byram Healthcare. For a 3 month supply it is $1,125 Dexcom G6 sensors, $900 for Omnipod pods. Transmitters are $210 for 2, each one lasts for 3 months. I could use advice as well. Hope this helps you too.
I remember using an insurance broker a while back to help navigate my options. It was a free service with the health insurance marketplace at the time.- if they’re still doing it perhaps working with one would help you decide on a plan.
Yes, thank you. My friend who is a rep is a real help and my boss is offering health insurance now too.
I have gold co-pay with BCBS arizona, it covers about 50% of dexcom, i paid about 100$ per transmitter and 130$ for 3 sensors. Im paying like 481$ per month as a single male tho… Not sure if i should switch to the lower silver co pay
Thank you so much for your replies and help! I’m self employed in FL, so I would be going private. I had a bronze level blue select for 2020 for which I paid $344/month. I was considering keeping my insurance at that level and going with a gold level myBlue for my husband, since out pocket for his Medtronic supplies was about $3000 to start him this year. And thank you for the spreadsheet suggestion, I love excel so that’ll be very helpful too! And I will also speak to an insurance agent for further counsel. Thank you hall again so much!
Occasionally my insurance needs authorization in order to provide a particular service or medication (not necessarily diabetes related). As I understand it they need some additional info from my doctor as to why the particular item would benefit me more than another option. I’ve gotten notices about a few the past couple of years and my doctor’s office is quite adept at managing them. It’s different from an appeal and hopefully easier - ask your insurance rep so you’ll understand. It may not be an issue but since this is new to you it will be helpful to know just in case it comes up.
Also - have his supply provider do the work of deternining the details of coverage under your policy: they’ll run things through and let you know about co-pays, percentage covered and your out of pocket costs based on his coverage and their contract. Familiarize yourself with the policy benefits on durable medical equipment as well as pharmacy coverage (some items now fall under pharmacy with some carriers - your insurance friend can help you navigate that) so you’ll be able to tell if something they tell you does not sitar to match up with their policy documents (the policy says ABC is covered 80% but the supplier says 50% when they calculate the order). If you differ and they push back, have your insurer intervene - it’s much more efficient than trying to do it yourself. Sometimes we “civilians” try to do it and it becomes frustrating, so it’s best to leave it to the pros (I’ve discovered that personally).
Things may very well go smoothly - this is to help you be prepared just in case.
1 Like
I have a similar question. My young adult T1D daughter is looking for insurance on the open marketplace, but it seems that every plan will cost the full $8K/year OOP plus the cost of the premiums. Each plan is confusing, will cover Humalog, but only as Tier 4, so $300/month until deductible is met, then $100/month, but Novalog isn’t covered at all, etc. Each plan seems to have a way to discourage T1D people from signing up and they all have some gap that means we will pay the full $10K ($8K+premiums) no matter what. Does someone have a marketplace insurance plan that costs less than 10K/year, or is this normal for a T1D not on an employer plan?
Carol Ramsey
I hate to add another layer of possible confusion, but regarding which insulins are covered - a while back my insurance sent me (and doctors) a notification that Novolog was no longer their preferred formulary. Patients using it would be required to switch to [I forget which one] unless physician notified them in writing that there was a reason why only Novolog would do. In my case their alternative had not been approved for the pump; people may have documented allergic reactions to one vs. the other - doctors know how to handle the things.
All of that is to say, it might be worthwhile to do additional research to see if there are exceptions. Look deeper in the policy details to see if additional authorization will cover what you use - or ask your doctor if you can change. My doctor’s office is very knowledgeable about what plans cover what and are “easier” to work with. Yours may well have experience with the plans available in your area and be able to give you guidance.
Hi Carol @carolramsey, one of the better ways for your daughter to find “the best” insurance plan for herself, is for her to gather ALL her medical information - medicines she uses, doctors she prefers, related medical devices, etc. - and for her to visit a good, professional, independent insurance broker and toll her/him what she wants.
I’m NOT an insurance broker, but I was impressed with one I visited last year when he laid out coverage offered by all major insurance companies; end result, he told I already had the plan the best fitted my needs. And, there was NOT any charge for this service.
Thank you for your help!
Carol
I’m researching and looking at health insurance options as an individual, after a 2 mo. furlough (C-19) and layoff by my employer. I have until the end of Jan. 2021 to decide on new plan/open enrollment. My experience with Cobra, even if for myself only, is the premiums are so expensive, it taps me out monthly, making co-pays and DME or Rx needs very difficult.
In researching how to choose a comprehensive plan for T1 needs, I found this very helpful worksheet online from jdrd.org: http://affordableinsulinproject.org/wp-content/uploads/2017/09/Worksheet.pdf?_ga=2.102640513.1204046255.1609956127-1296061662.1609956127
Check it out if you want to get a better understanding on you T1 medical costs/needs. May help you better determine a health care plan that best meets your individual needs.