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Thread: understanding pumps & insurance coverage (Tricare)

  1. #1

    Default understanding pumps & insurance coverage (Tricare)

    I'm trying to understand how pumps and cgms work and how they are covered with insurance. We are 3 months into D (Oct 26, 2011) and are on MDI. We have Tricare Prime North. I would like to talk to our endo about getting a pump. If there is anyone who can help me, here's what I would like to know:
    1. Does tricare cover all 3 of the major pumps (Medtronic, Animas and Omnipod)? (I did call them but they didn't specify that they only approve a particular pump.)
    2. Is the pump considered DME and everything else pharmacy? Or are the sets and pods considered DME and only insulin pharmacy? Is there an annual cap for supplies?
    3. Is it hard to get approved for a pump? Or did it take multiple times? How about for a cgm? (He drops into the 50's!)
    4. How does coverage change once he retires in 2 years? Do we pay more out of pocket?
    5. Understanding pumps, are the "sets" the tethered part that stays in him and connects to the pump itself? And many different companies make them not just the pump companies? Is there an application piece that gets removed or is it all one piece?
    I know this is a lot. I have tried to do the research myself before posting this, but I just couldn't find specific answers. I looked on the tricare website, but everything is so generic.
    Thank you all so much for helping me understand, even is you don't have Tricare.

  2. #2
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    Quote Originally Posted by buckmarko View Post
    I'm trying to understand how pumps and cgms work and how they are covered with insurance. We are 3 months into D (Oct 26, 2011) and are on MDI. We have Tricare Prime North. I would like to talk to our endo about getting a pump. If there is anyone who can help me, here's what I would like to know:
    1. Does tricare cover all 3 of the major pumps (Medtronic, Animas and Omnipod)? (I did call them but they didn't specify that they only approve a particular pump.)

    I believe that they do, my daughter uses the animas ping so I can say yes for that brand with certainty.

    2. Is the pump considered DME and everything else pharmacy? Or are the sets and pods considered DME and only insulin pharmacy? Is there an annual cap for supplies?
    The pump is dme. We get the sets, cartridges, IV prep and IV 3000 through animas with no co-pay.

    3. Is it hard to get approved for a pump? Or did it take multiple times? How about for a cgm? (He drops into the 50's!)

    The pump was easy, we had it in our hands within a week or 2. We tried to get her the dexcom cgms but were denied because of age. We haven't appealed the decision.
    4. How does coverage change once he retires in 2 years? Do we pay more out of pocket?

    We have a long way for this but I know there are retirees here who will chime in.
    If you choose to go with Animas or Minimed your endo has to fill out a medical necessity form for the One Touch ultra test strips otherwise you'll have to pay the non-formulary copay.
    Tammy
    Mommy to:
    Miss Caelin, 6 Dx 4/21/08 Pumping with Apidra in a Pink PING 5/17/10

  3. #3

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    1. Does tricare cover all 3 of the major pumps (Medtronic, Animas and Omnipod)?Yes, TRICARE will cover all brands of pumps & pump supplies when ordered by your endo.

    2. Is the pump considered DME and everything else pharmacy? Or are the sets and pods considered DME and only insulin pharmacy? Is there an annual cap for supplies?Pump & pump supplies are considered DME. Insulin, BG strips, and ketone strips are pharmacy items. The family catastrophic cap for Tricare Prime is $3000 for a family. In 2010 I got DS a new pump, new CGM, ordered supplies at earliest reorder date trying to max out. Non DS son even broke his leg & had lots of ortho/PT care in this year. Got to about $2800. So appears pretty tough to reach annual cap unless something, well, catastrophic, happens!

    3. Is it hard to get approved for a pump? Or did it take multiple times? How about for a cgm? (He drops into the 50's!)In my experience back in 2004 when DS was dx'd--standard line was "insurance won't cover pump until 12 months." From the start I was injecting him numerous (>10) times/day mimicking a pump, kept meticulous BG/carb/dosing logs. Kept demanding a pump every time I saw the endo (we worked in same MTF so saw him almost daily, although I didn't know him until DS was dx'd). Finally started on pump 2 months after dx, which was 2 months too long IMO. So think the obstacle to getting pump covered might just be the endo, not necessarily TRICARE. If you want a pump for your child, demand it. If the endo is not supportive, find another endo. If pump gets denied by TRICARE, find out what is missing to get it approved. Do not take no for an answer. As for CGM--think they are more readily approved now by TRICARE, if your endo words the letter of medical necessity with certain buzz words that trigger approval and include documentation of BGs that support the need i.e. nighttime lows. hypoglycemic unawareness. My son has used the CGM since they were first approved by FDA in 2006. Paid out of pocket for 2-3 years but then found other parents on CWD reporting it was getting covered. Off & on they still deny sensor coverage--I challenge the denial, send in BG logs and documentation requested & they get paid for. So appears to be a covered benefit. Again, I would switch endos if I wanted a CGM for my kid & they did not support it.

    4. How does coverage change once he retires in 2 years? Do we pay more out of pocket?While on active duty, the pump, pump supplies, CGM, sensors, pharmacy items are all 100% covered, at least for now. Once retired, if you continue Tricare Prime the copay is 20% for the DME items. Can't encourage you enough to get the big ticket items of pump & CGM while on active duty, and try to get a nice stockpile of supplies if you can. I would be glad to look up & tell you how much the 20% adds up to roughly for the annual supplies (using MM pump) once retired. Last year I replaced DS out of warranty pump. First pump from 2004 cost me nothing when on active duty, new pump in 2010 I had to cover 20% copay based on TRICARE's negotiated cost with Medtronic. Same thing with CGMs. They have 6 month warranty but usually last over a year or more in my experience--get it while on active duty for no copay, costs you 20% of negotiated cost for it once you are retired. Sensors also have no copay on AD, 20% once retired.

    5. Understanding pumps, are the "sets" the tethered part that stays in him and connects to the pump itself? And many different companies make them not just the pump companies? Is there an application piece that gets removed or is it all one piece? Medtronic, Animas, and Omnipod are basically the 3 pump options in the US currently. I would encourage you to make a choice based on whatever pumps/features are on the market now, not whatever any one company is swearing is just around the corner. Everyone on this board will attest to waiting & waiting for products to come out that just never come, or certainly don't come tomorrow when rumor swears the companies are "this close" to FDA approval. So try out all the brands and then make as educated a selection as you can based on the products out now. IMO all the pumps are good pumps, just have to pick based on the features & customer service reputations that are most important to you. Whatever brand pump you choose, you will have the non-disposable pump that will be warranted for 4 years (so try out all the brands & make best choice as another will not be covered for at least 4 years), then you will need an ongoing source of disposable supplies needed to keep your brand pump functioning day in and day out. Generally this includes a reservoir (basically the syringe that fits inside pump to hold 3-day insulin supply) and the infusion set, which is generally the tubing and needle/catheter part that attaches to the skin. Medtronic & Animas have several different choices of infusion sets to try--there is always a port that stays on the skin when disconnected for a shower, etc. Some sets disconnect right at the port, some disconnect in the midst of the tubing somewhere. The brand pump you chose will dictate what sets you use, but there are comparable sets for each pump brand. You also need alcohol pads/IV prep wipes and sometimes IV tapes to help keep sets attached. I am sure someone with Omnipod experience can share exactly what supplies they need on an ongoing basis.

    Whew, hope this helps! Let me know if I can help you in any way!

    Mom to DS (12), dx'd Jul 2004, pumping MM since Oct 04, CGMS since Oct 06
    Also Mom to non-D son (14) and non-D daughter (6)

  4. #4

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    We have had no problems with tricare prime and approval of pump, CGM and supplies! As long as Endo has written the scripts tricare has approved it! My son has had minimed pump and cgm and now he is on omnipod and dexcom cgm. We are covered at 100% for dme and get everything but his insulin through the supplier ( we use edgepark!). Edgepark calls every year when dexcom warranty is up and we start the process of getting a new one when needed. I do not know much about the retired cost though as my husband is still active duty. Hope that helps!
    Veronica 34 Military wife to Matt married for 16 years
    4 children Alexis 14yrs (GAD POS beginning July 2010) officially diagnosed 11/25/13 pumping omnipod and CGM Dexcom G4, Blake 11 yrs, Tyler 9 yrs and Matthew 8 yrs dx'd @ 9mon old pumping Omnipod and CGM Dexcom 4G (sometimes we revert back to MM) We love both!!

  5. #5

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    Quote Originally Posted by buckmarko View Post
    I'm trying to understand how pumps and cgms work and how they are covered with insurance. We are 3 months into D (Oct 26, 2011) and are on MDI. We have Tricare Prime North. I would like to talk to our endo about getting a pump. If there is anyone who can help me, here's what I would like to know:

    1. Does tricare cover all 3 of the major pumps (Medtronic, Animas and Omnipod)? (I did call them but they didn't specify that they only approve a particular pump.) To the best of my knowledge they cover all 3. We have Animas One Touch Ping for both boys and it covered it at 100%

    2. Is the pump considered DME and everything else pharmacy? Or are the sets and pods considered DME and only insulin pharmacy? Is there an annual cap for supplies? I have no idea. We get our supplies for the pump from Animas (cartridges, tubing, IV3000, IV Prep wipes). We get our insulin, strips, etc at the Naval Hospital. All are covered at 100% doing it that way. If you get insulin, strips, etc through Express Scripts or a pharmacy out in town (like CVS) then there is a copay.

    3. Is it hard to get approved for a pump? Or did it take multiple times? How about for a cgm? (He drops into the 50's!) We had no issues with approval for the pump. We don't have a CGM. We filled out the paperwork and sent it in. They called me to let me know Tricare Prime covered it at 100% and then they got the prescription stuff from the doctor and we received it a few weeks later.

    4. How does coverage change once he retires in 2 years? Do we pay more out of pocket? I know nothing about retirement, but I believe there are copays involved after retirement.

    5. Understanding pumps, are the "sets" the tethered part that stays in him and connects to the pump itself? And many different companies make them not just the pump companies? Is there an application piece that gets removed or is it all one piece? We use the Contact Detach set. There is a tube (the cartridge) that the insulin goes into that we change every 4 days (in our case). This goes into the end of the pump. The tubing is connected to that cartridge and then there is a second connecting tube that has the needle that is inserted into him. There is a place to disconnect the pump from the tubing between the 1st and 2nd pieces. We chance the piece of tubing with the needle every 2 days.

    I know this is a lot. I have tried to do the research myself before posting this, but I just couldn't find specific answers. I looked on the tricare website, but everything is so generic.
    Thank you all so much for helping me understand, even is you don't have Tricare.
    As a side note, I just learned that Tricare does not authorize you to have autoship set up for your supplies for your pump. I had initially signed up for it, and then realized when our supplies were getting low that I hadn't gotten a shipment. When I called they told me, but hadn't mentioned it when I initially signed up for it. So, that is just something to be aware of to prevent problems with running out.


    ~Mom of 3~
    Derek, 12, T1 dx'd 1/12/11...Animas Ping as of 11/22/11
    Logan, 8, T1 dx'd 9/28/10...Animas Ping as of 8/23/11
    Paige, 4, non-D

    Found out both boys are actually MODY 2.

  6. #6

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    Quote Originally Posted by Lisa1001 View Post
    As a side note, I just learned that Tricare does not authorize you to have autoship set up for your supplies for your pump. I had initially signed up for it, and then realized when our supplies were getting low that I hadn't gotten a shipment. When I called they told me, but hadn't mentioned it when I initially signed up for it. So, that is just something to be aware of to prevent problems with running out.
    That's odd. We have always been on auto ship. We got out minimed supplies auto ship and now our pods auto ship. Strips, lancets etc are also auto ship and I have never had a problem.
    Veronica 34 Military wife to Matt married for 16 years
    4 children Alexis 14yrs (GAD POS beginning July 2010) officially diagnosed 11/25/13 pumping omnipod and CGM Dexcom G4, Blake 11 yrs, Tyler 9 yrs and Matthew 8 yrs dx'd @ 9mon old pumping Omnipod and CGM Dexcom 4G (sometimes we revert back to MM) We love both!!

  7. #7

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    I don't know. I got one order autoship, but when I called about why I didn't receive December's order they told me that Tricare didn't allow autoship. I get it for other meds (non-D) that I have to get through Express Scripts with no problems, though.

    I'll check with them again when it gets close to needing a new order. I'll probably get a different answer then.


    ~Mom of 3~
    Derek, 12, T1 dx'd 1/12/11...Animas Ping as of 11/22/11
    Logan, 8, T1 dx'd 9/28/10...Animas Ping as of 8/23/11
    Paige, 4, non-D

    Found out both boys are actually MODY 2.

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