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Insurance/ pump question

Discussion in 'Parents of Children with Type 1' started by BittysMom, Jan 31, 2012.

  1. BittysMom

    BittysMom Approved members

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    After speaking with my insurance co. it seems a pump would be under durable medical, and we have a $2k deductible for that. Then we pay 10% of remaining. However, they have a cap of $1500 per year on durable medical so basically they would only be putting $1500 toward a pump.

    Each year I have the $2000 durable medical deductible so what I'm wondering is if the infusion sets/ tubing/ reservoirs etc are usually considered durable medical? She couldn't tell me without the code which I don't have off hand.

    Thanks for any info.
     
  2. MomofSweetOne

    MomofSweetOne Approved members

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    Our tubing, sets, reservoirs, Skin prep, IV 3000, Hypafix, etc. is considered DME for our insurance. Medtronic bills the insurance for us; it's very convenient and quick. I think others sometimes get it as prescription?
     
  3. sarahspins

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    I could currently get infusion sets (but nothing else pump related) under my RX benefits, however the ordering process is stupidly complicated because they aren't a stocked pharmacy item, and my price that way (my co-pay) is within a dollar of the insurance contracted rate if I just order them as DME (I pay cash for that until I reach my $2500 deductible)... so that's what I do.

    I pay for tape and adhesive out of pocket, just because it's not that much yearly (well under $50 since I use flexifix which comes on a roll, rather than individually packaged tape which costs about 10X as much) and while the price could be applied to my deductible if I got an RX for those items, not having one allows me to shop around and get the best price.
     
  4. JaxDad

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    It's Rx for us. Do you have to order your sustaining/repetitive prescriptions or can you get them through your local pharmacy?

    I'd suggest you call the company or local pharm and ask them to see what your share would be. They should be able to answer you with item descriptions and without the numbers.
     
  5. Mish

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    Those items have always been durable medical for me as well.
     
  6. BittysMom

    BittysMom Approved members

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    Thanks everyone. I'll have to see what I can find out. We may look to change insurance co's too, as we often do since my husband is self employed.
     
  7. acoppus

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    We had a $2500 limit on durable medical devices, but somehow Medtronics convinced our insurance to pay the full cost. Check with your pump reps and doctors to see if they can help you. It did help that our endo said the pump was medically necessary to ensure Tyler got the small doses that he needed.
     
  8. mmgirls

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    You need to ask if the cap applies to "diabetes care supplies".

    Two insurances I had had a yearly and liftime cap, but Diabetes items where excluded and had no cap, I found out when I thought I was going to have to pay in full for something but the insurance picked it up.

    Please call your insurance company and ask if there are any exclusions to the cap or soecifically Diabetes care items.
     
  9. Gomod71

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    Our plan considers pump,pump supplies, sensor and transmitter durable medical. Test strips and insulin were Rx.

    We had a $2500 deductible per person (5K family) and then diabetes supplies were covered at 80%. There was no cap on Diabetes supplies - look for specifics on your plan.

    We just switched the kids to a state program that we are paying for ($270 mth for each kid). In the long run, at the end of the year, the bottom line was better on this plan rather than DH's employer's plan. The pump was out of warranty last month.

    The new insurance covers pump, pump supplies and test strips at 100%.
     
  10. dqmomof3

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    Test strips are under both benefits for us. My health plan has one benefit where for one copay, I get 150 test strips, but only if I get those at the pharmacy. So we do that, and then I order the rest of our test strips from CCS Medical, which is paid under DME. Pump sites, pods, reservoirs, etc.. are always DME for us.
     
  11. Jake's mom in NC

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    We have Blue Cross and have a $2500 deductible as well, but I called and spoke to 5 different people before I finally got someone to connect me with "member health" program and it waives the deductible for all diabetes testing supplies.
     
  12. Lisa P.

    Lisa P. Approved members

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    If you find insurance covers supplies like an RX, you might look into the Omnipod since the up front costs are less.
     
  13. manda81

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    I think it all varies, unfortunately.

    We have the same deductible, but for us while all the pumps were covered the same way (and we were going to be paying 2k+ out of pocket, the Omnipod was somehow covered at 100%, and had no deductible.

    We have paid nothing at all for it, not for the system, not for the pod-replacements which are shipped quarterly, etc... nothing.

    I have no idea how that works.
     

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