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Anyone have UHC with $2500 Diabetes cap

Discussion in 'Insurance Issues' started by SPICYSMOM, Apr 24, 2010.


    SPICYSMOM Approved members

    Jan 5, 2008
    I do, and still having to figure it out. Someone on Tudiabetes.com said she is fighting with UHC because they consider the omnipod pods to be pumps and therefore go for this cap. The bigger problem of them not covering over $2500 in a year (and the extra money you pay not going towards the high deductible) is that this is apparently a 3 year cap. It would make sense if it was an actual pump they did not want to pay for more than every 3 years, but the pods only last 3 days.

    I just switched over to the omnipod and have had my first order of pods received. I do not know what the result will be yet.

    Anyone dealing with UHC on this matter?
    Afraid about insurance for the first time. I may have to go back to MDI if this is true - which I have not been on since 1997.
  2. MyAngelEmma

    MyAngelEmma Approved members

    May 23, 2008
    We used to have UHC insurance and when I questioned them about the DME cap I was told it does NOT apply to Diabetes. I know every plan is different but if you haven't already I would ask to talk to a supervisor to be sure the cap applies in your situation.

    SPICYSMOM Approved members

    Jan 5, 2008
    The $2500 is very differently part of diabetes

    FROM the UHC benefit document:
    Insulin pumps and supplies for the management and treatment of diabetes, based upon the medical needs of the Covered Person. An insulin pump is subject to all the conditions of coverage stated under Durable Medical Equipment. Benefits for blood glucose monitors, insulin syringes with needles, blood glucose and urine test strips, ketone test strips and tablets and lancets and lancet devices are described under the Outpatient Prescription Drug Rider.

    Durable Medical Equipment

    Durable Medical Equipment that meets each of the following criteria:
    ? Ordered or provided by a Physician for outpatient use primarily in a home setting.
    ? Used for medical purposes.
    ? Not consumable or disposable except as needed for the effective use of covered Durable Medical Equipment.
    ? Not of use to a person in the absence of a disease or disability.

    Benefits under this section include Durable Medical Equipment provided to you by a Physician.

    If more than one piece of Durable Medical Equipment can meet your functional needs, Benefits are available only for the equipment that meets the minimum specifications for your needs. If you rent or purchase a piece of Durable Medical Equipment that exceeds this guideline, you will be responsible for any cost difference between the piece you rent or purchase and the piece we have determined is the most cost-effective.

    Limited to $2,500 in Eligible Expenses per year. Benefits are limited to a single purchase of a type of DME (including repair/replacement) every three years, combined Network and Non-Network.

    Examples of Durable Medical Equipment include:
    ? Equipment to assist mobility, such as a standard wheelchair.
    ? A standard Hospital-type bed.
    ? Oxygen and the rental of equipment to administer oxygen (including tubing, connectors and masks).
    ? Delivery pumps for tube feedings (including tubing and connectors).
    ? Braces, including necessary adjustments to shoes to accommodate braces. Braces that stabilize an injured body part and braces to treat curvature of the spine are considered Durable Medical Equipment and are a Covered Health Service. Braces that straighten or change the shape of a body part are orthotic devices, (except for podiatric appliances for the prevention of complications associated with diabetes), and are excluded from coverage. Dental braces are also excluded from coverage.
    ? Mechanical equipment necessary for the treatment of chronic or acute respiratory failure (except that air-conditioners, humidifiers, dehumidifiers, air purifiers and filters, and personal comfort items are excluded from coverage).
    ? Burn garments.
    ? Insulin pumps and all related necessary supplies as described under Diabetes Services.
    ? Podiatric appliances for the prevention of complications associated with diabetes.

    Benefits under this section do not include any device, appliance, pump, machine, stimulator, or monitor that is fully implanted into the body.

    We will decide if the equipment should be purchased or rented.
    Benefits are available for repairs and replacement, except that:
    ? Benefits for repair and replacement do not apply to damage due to misuse, malicious breakage or gross neglect.
    ? Benefits are not available to replace lost or stolen items.
  4. t1mom

    t1mom Approved members

    Oct 18, 2008
    Had that coverage for 2 years we were finally able to switch and replace our out of warranty insulin pumps
  5. Flutterby

    Flutterby Approved members

    Nov 11, 2006
    I wouldn't think the pods itself would apply, but rather the PDM portion.. for a tubed pump, they would cover the sites each month, including reseveroirs, and you could replace the pump itself every 3 years.. this is what I'm getting out of it.. but I'm in no way an insurance person LOL, and they can and do what they like..

    I agree about calling and asking to speak to a supervisor.

    SPICYSMOM Approved members

    Jan 5, 2008
    UHC paid for pods under medical

    UHC just paid for the 5 boxes of pods under medical. Edgepark charged $2500 and UHC paid $1500 - $300/box.

    I hope that means come July 1st when my new insurance year starts that I can purchase them under the $300/box price.

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