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Thread: What do you think of this insurance coverage? Opinions, please.

  1. #1

    Default What do you think of this insurance coverage? Opinions, please.

    PPO plan
    Prescriptions $75.00 deductible per individual, after that 80/20, monthly.
    --Insulins being $80-100 per bottle, retail not co-pay cost
    --test strips being around $100 per 100 strips, retail not copay cost
    --glucagon being $100.00 per kit retail

    DME has a $500 deductible per individual & $1000 per family
    $3000 maximum out of pocket per year
    no DME maximum on plan for supplies

    Dr. visits are 80/20 or 70/20, depending on Dr. after the $500 deductible is met.

    Insulin pump coverage is 70/30; but has to be preapproved and they pro-rate their payments over 12 months. If you buy it, they wouldn't re-imburse you all at once...you would get 1/12 of the amount for 12 months.

    No alcohol, ivprep, betadine wipes covered
    Numbing cream not covered under DME or MMS...maybe under pharmacy
    No tapes of any kind covered
    No lotions/creams covered

    Infusion set and resevoirs are covered under the 80/20 or 70/30 (depending if they are Preferred) and after $500 is met.

    and...
    Cost of $150.00 per month from employer plan.
    Last edited by thebestnest5; 01-03-2008 at 11:05 AM. Reason: clarification of cost

  2. #2

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    $150 per month sounds really reasonable - we pay about 10x that.

  3. #3

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    It sounds like you get what you pay for. $150/month for a family is very very inexpensive. (Is that $150 for the whole family?). But the coverage is pretty minimal. Not the worst in the world, but not great.

    When you listed prices for the insulin and test strips -- is that what you have to pay, because that's about full price.
    Brenda, dx'd type 1 6/07 at age 30 while in the TrialNet research study. MDI Lantus and Novolog, Celiac (3/07).
    Mom to Carson, age 13, dx'd at 9 months. Cozmo (1/05) Navigator (3/09), Dexcom (8/10), currently on T-Slim (4/13)
    And Mom to Henry (nond), age 10, training for the US 2024 Mens Gymnastic Team

  4. #4

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    At first glance it looks good to me, it's cheaper than what I pay! You might get less costs with a lower-priced POS plan, with less choice of doctors. But a PPO (no-referral) really doesn't help with D unless your GP refuses to refer you to a endo you want to keep. It's pretty easy to go GP shopping!

    Another major factor to consider would be whether you have a cafeteria plan, which can really cut down the cost of copays, OTC stuff, travel expenses, etc.

    What other choices do you have?

  5. #5

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    Quote Originally Posted by Ellen View Post
    $150 per month sounds really reasonable - we pay about 10x that.
    Ouch! Do you have an employer plan?

  6. #6

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    Quote Originally Posted by BrendaK View Post
    It sounds like you get what you pay for. $150/month for a family is very very inexpensive. (Is that $150 for the whole family?). But the coverage is pretty minimal. Not the worst in the world, but not great.

    When you listed prices for the insulin and test strips -- is that what you have to pay, because that's about full price.
    That's full price per bottle and per 100 strips.

  7. #7

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    Quote Originally Posted by saxmaniac View Post
    At first glance it looks good to me, it's cheaper than what I pay! You might get less costs with a lower-priced POS plan, with less choice of doctors. But a PPO (no-referral) really doesn't help with D unless your GP refuses to refer you to a endo you want to keep. It's pretty easy to go GP shopping!

    Another major factor to consider would be whether you have a cafeteria plan, which can really cut down the cost of copays, OTC stuff, travel expenses, etc?

    What other choices do you have?
    Not sure on the other choices, yet. I need to do some more checking. I am not impressed that they do straight percentages and not fixed dollar co-pays.

    Where are the insurance plans that have $0 co-pays on insulin and cover pump supplies 100%? The plans that actually cover tapes and other supplies?

  8. #8

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    I'd have to do the math, but based on what you have presented here, I would think you'd be better off paying out of pocket or buying strips on Ebay because those coverages are not very good at all.

    At $150 per month for 12 months, that's $1800. That will buy you 900 test strips alone. Then you can buy insulin for only a few more dollars per vial with no deductible (which adds $6.25 per vial assuming you use 1 vial per month). I think at retail fast-acting insulin is $88 per vial (Drugstore.com), and so your insurance isn't saving you anything on insulin.

    Pump supplies are a whole other story, and I don't have enough details to work it out.

    With doctor visits, if you will tell them you are paying cash they will give a BIG cash discount if you pay at the time of visit. Check with the endo's office on that one.

    My insurance is through UnitedHealthCare, and we pay zip except for 10% on pump supplies (which is why we use A+).

    All that being said, it is a PPO, so have you tried A+ yet?
    Type 1 Diabetic since 2001. Minimed 722 with Novolog and CGMS.

    Dad of Emma, age 9, diagnosed at 9 months pumping with MM REVEL CGMS and Novolog. She also has been diagnosed with Hashimoto's Disease, Juvenile Rheumatoid Arthritis, Glomerular Nephritis, Multiple-Autoimmune Complex, along with lots of other stuff that makes doctors shrug and say "I dunno."

    Brenden, aka "Rhino" age 14. Starting tailback for Clovis Freshman Academy (had to say it).

    Husband of Emmasmom.
    www.toosweetboutique.net

  9. #9
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    We have a PPO and are paying $20 for reg dr, $40 for specialist. Prescriptions are $10/20/35 depending on what they are (insulin is $20). Ours is a PPO (BCBS) and I really like the coverage we are getting. We do have to pay 20% for pump supplies which is why I tried A+. Ours is also a little more than $170 a month for family coverage...(did I mention how much I like my DH employer). These actually just went up yesterday.... (why would someone pay $100 for ER visit for sinusitis when an Urgent care visit was only $30??? have not figured that out yet)... abuse of the insurance by some of the salaried people has all of our copays and deductibles.

    I would keep looking around to see what else they offer.

    Stephanie
    Mom of:
    Danielle, 17 (singingdiabetic9993), diagnosed 12/05 at age 12.
    Pumping with an Purple Minimed Revel, Mios
    diagnosed 11/08 with Auto-immune Thyroid, no meds yet
    Matthew, 14, non-diabetic
    Wife of Brian, 22 years

    http://bsdmhutch.blogspot.com/

  10. #10

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    Is the pump percentage based on the cost the insurance has negotiated with the pump company? For example, Minimed's list price is like $6,200, but they have a negotiated price of $4,600 with my insurance, so 30% of $4,600 is a big difference from 30% of $6,200.

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