CGMS Approved by Tricare Prime...

[Bklyn1775]

I have recieved good news today... Tricare Prime which is the health insurance carrier for military and their dependents has authorized the CGMS for my Son Tristan. For all of those who were wondering if this was a covered item under Tricare, it is.....


Sophy Velez
Mom to Tristan age 8 (Dx'd 3/2003, Matthew age 6, Joshua age 5 :cwds:

[EmmasMom]

:D That's Wonderful News!!!!!!!!

I'm sure any other military families will be thrilled!

[ecstaticlght]

Thank you for the info. My son's endo was hinting at working with the CGMS at his last visit..hmmmmmmm

Did they require any special circumstances and is this for a short period to get a good reading on the BG's or always wearing it? The endo was hinting at always with my son.

[Bklyn1775]

No Problem, they did not require any special circumstances.... they also did not specify a certain time frame. they do not seem to place any limitation on items that are related to Diabetes Management. So far i have really good experiences with them....as far as Insulin Pump, CGMS....

[frizzyrazzy]

AWESOME!! That's really good news.

[ish's daddy]

how much does prime cover?(i.e. what % do they pay)

[semperwife]

Do you have the insurance billing code? My authorization person said she needed a code.

Thank you,
Brandy

[Bklyn1775]

All you have to pay is a $9.00 Co-pay. I beleive you have to pay this everytime you get an order of sensors. I will keep you guys updated.

[Bklyn1775]

SemperWife,
Minimed told me they did not have the necessary billing codes for the CGMS. I called Tricare and explained this to them and they stated that Minimed can run the request through with the required documents (prescription, letter of medical necessity) and they would apply the appropriate codes for the CGMS. Let me know if this helps or if you need additional info.

Sophy

[Lindy]

Sophy - when you called Tricare - did you ask to speak with a specific dept?? What region are you calling from?? And - were they able to give you an answer right away?? My son's info is in to Medtronic and received a call from them today about Insurance info - so we should be making contact this week and I am anticipating some issues - but perhaps it will go smooth also for us.. Any and all info you can provide would be really appreciated!! Right now we are requesting the Guardian only - not the pump, which may be a difference... Thanks a ton!

[Bobbie]

Sophy, I'm so glad you posted this information! We should have an appointment this month with our Ped Endo. I will mention this to him and see what he says.
I'm curious as to how many Tricare Prime families have been able to get the CGMS. Is your son on a pump? If so, did you need an upgrade? And did Tricare pay for that also?
Sorry for so many questions but often times the parents know more than the doctors do.
Great News!!:D

[Bklyn1775]

Lindy,
When I called Tricare, I was referred to the department that can check your benefits in regards to what is covered by Tricare and what is not. I am calling from Region 1, and as soon as I asked about coverage...they responded that the CGMS was in fact covered. I called several times, you know how it is dealing with Tricare. You have to verify something several times..each time they stated it was in fact covered. I had no issues with Tricare or Minimed...it has been a smooth process. I am so happy with Tricare because they have covered both the Pump and the CGMS with just a simple $9.00 Co-pay each. Just remember that Tricare will require a letter of medical necessity from your DR....

Sophy

[Lindy]

Got the call today - Tricare approved it and they are shipping... YEAH!!! Here is my recommendation - don't call Tricare as the CSR's have NO CLUE what a CGM is and if it will be covered or not.. Do the paper work and let it ride until you hear back - it was so frustrating to call Tricare myself because I never could get thru to a person who knew what I was talking about.... but yeah - the system worked!!!! And the Guardian is coming this week!

[Bklyn1775]

Congratulations on the good news!!!

[Twinklet]

Tricare and their inconsistencies in policy are frustrating me.

Another military wife who is a friend of mine is trying to get covered for a CGMS. She's had T1D for 30+ years and has been pumping with a Minimed for several years. She just got a 522. Tricare is really giving her the runaround about the sensors. She got an E-Mail from her Endo's office today saying the CGMS is considered a "luxury" and needs to be medically justified.

I'm noticing that many of you who have had it approved quickly and without incident are in the North Region. We're in the West Region. It is very frustrating that Tricare has what seems to be differing policies and different coverages in their different regions!

I'm interested to know what those of you in VA will be approved for. Please post when you find out. She will be moving there soon.

[Twinklet]

After spending a lot of time on the phone, we have discovered that Tricare North/East region is the ONLY region currently covering CGMS. Tricare-West will not cover it at all, and Tricare-South doesn't even have the HCPC codes in their computer.

If you are a military family with CGMS paid for by Tricare and are living in a region other than North/East, please send me a PM. Tricare coverage is supposed to be the same everywhere.

This is a real problem for people currently on CGMS and living in North/East region who have to move to another region. Their sensors may no longer be covered!

My husband is going to elevate this next week when he has some time off. If you have anything to contribute, please PM me. Thanks!

[mattinglyr]

Did Tricare really pick up coverage for the Minimed sensors? My daughter's pump will arrive Thursday and I need to know whether to start the battle to get the sensors paid for.

Thanks,
Ruth
Mom of Ellen, 15, pumper since 2001

[PixieStix]

You may want to do a search for "TRICARE" and you will see the posts regarding coverage over the past couple weeks. Uncertain what the status will be now, appears it will not be a pharmacy benefit but some indication to some beneficiaries that perhaps it will be a non-medical supply item, sounds like other beneficiaries have been told flat out "no" to coverage. At this point I am waiting to hear back from Medtronic whether the order I placed last week is going to be covered or not. Very frustrating!

[semperwife]

We got ours approved and have been using it just fine for 5 months.... now suddenly (since it is no longer a prescription benefit but a medical benefit) they require new authorization every 3 months, so we have been stretching and stretching our sensors to make them last only to have TriWest deny it. We received a letter saying that they are not covered according to the Tricare Policy Manual and it is a factual determination. They cited Policy Manual chapter 1, section 2.1 saying that it has not been established and is unproven and therefore excluded from coverage. WHAT??

How did that change in 5 months? How do you approve the purchase of the continuous glucose monitor purchase but then get denied for the supplies that go with it?

I am baffled.

[somanybakers]

We are in Viginia (I can never remember what region it is). We were told on the phone with Tri-Care, in January, that CGM was covered, the CGM was approved and shipped in February and then I got a letter in late March stating that it was not covered or ever approved and not to pay anything to Liberty Medical (co-pay) since they were incorrect in sending it since Tricare says it was not approved or covered.

I find myself wanting to fight about it with someone (Tri-Care) but we are no longer using it so I have let it go. It is all too much.

[AirforceType1mommy]

Weve been trying to get the deacon cgm approved for two years now. Arielle is now 4. They continue to deny it due to her age, they will not cover it until she is 7. I am going to keep fighting this battle but I was wondering if any of you have had this problem and how you went about getting it approved? I'm going to gather data from other children under 7 with the cgm. Its bar enough fighting the d battle...the. To battle insurance to cover a life saving device. Thanks xoxo Jessica