Tricare!!

[Lindy]

Tricare rep called this morning - telling me that the sensors and CGM are NOT a covered benefit. She was surprised to hear that we have had the CGM now for 6mths and said she doesn't see that anywhere in her computer - only the pump info for Cooper. I explained to her that it was previously a pharmacy benefit and that Tricare would now be covering it under durable medical equipment. She said that they just had a meeting on it and that it was not "proven" effective and that it is not a covered benefit - so I could appeal it if I wanted.. ARE YOU KIDDING ME!! :mad:

We have been covered for the past 6mths - and boom they just drop us?!! I'm so mad right now. She was going to talk to her superviser and get back to me today. I used the code from another thread and it came up DENIED!!! WTH??!!

I depend on the CGM every day!!! It is a SAFETY DEVICE - I just can't figure insurance companies out - I can be more aggressive at treating him with the CGM and hopefully helping his longterm outlook with less complications!

Anyone else have some luck with Tricare?:????????????

[momofphoenix]

I just talked with a Minimed pump rep on Friday, they said Tricare is very good about covering ALL pump and CGMS supplies..... I dont know what else to say to you other then I'm so sorry Tricare is being such a pain in the @$$..

If you get it approved or find a way around all the BS please let us all know. I am dreading dealing with them if Phoenix get's approved......

[Twinklet]

Well, you know my story. None of us here in CA are getting covered for CGMS at all (except Brandi). TriWest sent out letters to several of us stating that the CGMS is "unproven technology" and a "luxury"--if you can believe that! :mad: A luxury? Give me a break.

All you can do is appeal, appeal, appeal and see what happens. I hope they will at least keep paying for yours since you have been using it for 6 months! Good grief!

[piratelight]

Grrrr... :mad: I am getting ready to appeal as we were just denied a CGMS for Hunter. All I can say that can be printed here is :mad:

[Lindy]

my speaker phone is on - listening to music as I'm on hold with express scripts... so far have called foundation care, medtronic, tricare north and express scripts - I have been assigned a case manager thru medtronic, the regional manager is supposed to be calling me sometime soon and tricare north has sent our paperwork forward for a doctor's approval, if denied we are supposed to appeal..

but get this - on Oct. 24th Foundation Care received a call from LINDA - Express Scripts, Linda stated that they would no longer be covering sensors under a pharmacy benefit but would be covered under a medical benefit.. she gave them an incorrect phone number for all of us to call if we had questions.. and did NOT have anything in writing - only a phone call!

Express Scripts - is so confused they don't know where to go with the info I'm giving them - of course I'm looking for LINDA.. but give me upper level management so I can tear someone up..

I'm worried - that maybe Tricare is saying "whoops" these things are waaay to expensive and we are not covering them!

At this point I'd settle for a hefty co-pay, but to have nothing after being covered for 6mths - is just beyond frustrating!!!!!!!

And - to have NO ONE know what you are talking about - telling me that we shouldn't have ever been approved - it was a mistake - well thank god for mistakes because now we know how awesome the CGM is and ....

Good Lord - Express Scripts wants me to do an appeal now with Tricare North - just give me someone in upper management that knows WTF I am talking about...... the music is driving me crazy but so is the CSR on the phone trying to handle this call - lady you are just not qualified give me the person in charge!

well - so I have no updates - just frustration.. I'll keep you posted if I ever get off of hold!

[Jana]

Do you still have your original approval letter from Tricare? Can you take that into the office and show them that you were approved for a CGMS and make your appeal for continued coverage? See if your doctors (and maybe the chief endo) can supply you with additional statements of medical neccessity to help make your case.

We're in Tricare's north region. We haven't had any problems yet, but this is pretty frightening. Now that we're used to the Guardian, I don't know what we would do without it. It's a fantastic tool.

[Brensdad]

Funny how the government will spend $4.6 trillion fighting two wars but a CGMS is "ineffective."

[Momof4gr8kids]

Do you have any personal data to show, like reduced A1C, or tighter range? I'd start digging and find both articles stating it's effectiveness, and bring it home by showing how well it has worked for you when you appeal.

[momofphoenix]

Just out of curiosity I am going to call tricare tomorrow and see what they tell me.... I heard they are covering somethings in different regions and not other regions... that might be the case I'll call tomorrow

[twbeckman]

I submitted a sensor order to Minimed on 30 Oct after the phone call from Foundation Care...called today to check on the status--coverage was refused by Foundation Care (as expected), was told Minimed was resubmitting back to Tricare to find out if it will be covered elsewhere...fully expecting "no" but will be so frustrated!!!

Will post when I get a definitive answer on our end too. Should be a consistent benefit across the regions though I certainly do not understand how it all works but am willing to work for the good of all our kids (and adults too!).

[deafmack]

I am so mad for you, frustrated etc. :mad: I always tell myself that Insurance companies are not in it to help the consumer but for the bottom line, the almighty dollar. The CGMS is vital to help with control especially in children with type 1. If it were my child I would certainly want one.

[Brensdad]

I wonder if Tricare's sudden change of heart regarding the CGMS has anything to do with "Dr." Kahn's speech the other day?

[Lindy]

Not sure WHY this has happened - only know that it is happening.. Spent hours on the phone yesterday - and at one point had my cell phone and landline both on speaker phone so that express scripts, myself and foundation care could all be on the phone together - this lasted for nearly 2 hrs. It was interesting!

What I do know is that Tricare North was allowing the CGM's under a pharmacy benefit - billed thru Express Scripts. The reason for pharmacy was due to the fact that they were "kinda" thinking the sensor was like a glucose strip - which is why it fell under pharmacy.... Tricare said it was medical equipment and should be billed as such... fine, but the current billing doesn't allow for it!

Other Tricare regions were not allowing the CGM's period... Perhaps some complaints came thru and they realized that coverage needed to be the same across the US - so whala! NO MORE SENSORS!!

Yes - we will of course appeal.. I just don't understand how we had coverage for 6mths - and then without notifying us or giving us any information they say we no longer have coverage - is that legal??

Right now - a reserach specialist with Express Scripts - is tracking down the chain of events that led to us losing our coverage on the sensors - where the info came from, who said what etc.... Then we'll be making the call to Tricare (medical) to see if their policy will change regarding the CGM's... Cooper's paperwork has already been sent forward to a Tricare doctor for review - am sure we will have to appeal but right now we have the ball rolling!

What is beyond frustrating is that Tricare medical cannot see Tricare pharmacy - so the medical cannot pull up our records and see that Cooper has had the CGM for 6mths now... UGHH!

Please let me know how the rest of you are doing with this!

[twbeckman]

I was called today by MM, again to say that Foundation Care denied the claim but they are looking for an alternate way to get them covered. The rep told me she is working another TRICARE beneficiary too and said she is not giving up on us. In talking w/ her I told her there is an active thread going on here w/ frustrated beneficiaries who either had it covered and now don't and other who never have but want it and should have had it if other TRICARE regions covered it.

I told her that when I was active duty in Tricare South I ordered supplies directly from Medtronic, but once I retired and moved to the North I had to go through Liberty (don't know if this is true for everyone). Anyways, I think she was going back to TRICARE and also trying Liberty. She said she will call me again early next week and give me another update, which I will share w/ all of you. Not really feeling optimistic, just tired of fighting for everything all the time.

To boot, someone stole my "Cure Diabetes" and "I Love a Child w/ Diabetes" magnets off both my cars in my own driveway overnight...geez, am sure it was kids fooling around but somehow feel more outraged just because of their subject matter!

[Lindy]

OK - Express Scripts called tonight. The "research specialist" talked with a Tricare rep who was dealing specifically with the CGM matter. She was told that at NO time was the CGM a covered benefit and that it was a mistake - apparently thru Tricare North - that some of us got them.. They are now correcting that mistake and revoking our prior authorizations...

What a battle ahead!!! :(:mad:

And - yes we have to order everything thru Liberty in the North Region. I was told Medtronic does not have a contract with Tricare and so we must use Liberty for all of our supplies.. Liberty has tried to order the sensors for us but was denied also!

I'm thinking we need to band together and draft some fairly direct letters stating our medical needs for our children and question WHY the government isn't being a leader and utilizing the cutting edge technology that is available!!!!!

I'm too mad right now - and we are leaving tomorrow for our 3mth checkup (4hrs away) - making a weekend out of it... A few drinks - maybe $435/box of sensors won't seem so bad after happy hour?!