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Tricare Peeps/CGMS

Discussion in 'Parents of Children with Type 1' started by Twinklet, Jun 25, 2008.

  1. Twinklet

    Twinklet Approved members

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    We tried to get Tricare to cover a Guardian for us last summer and were flatly turned down, even on appeal. My DH took it WAY up the Tricare chain of command, write letters, faxed documents....and we were still turned down as they deemed CGMS devices "experimental". :(

    We were able to enroll in a study and get a CGMS for free. We were assigned the Navigator and we absolutely love it, but I got the price list for it today and I'm freaking out! It's WAY more expensive than MM or Dexcom.

    So I'm going to ping Tricare again to cover this when our study ends in the fall. If any of you have tips on how I can get it covered, please post or PM me.

    Otherwise, we'll have to most likely grab an MM or a Dex on sale. It's not worth breaking the bank over!
     
  2. Abby-Dabby-Doo

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    Andie~
    For all you've gone through, you deserve the little sucker for free! Wow, I hope at least a discount? :confused:
    I will PM you some information I have regarding the term "experimental" that I used in my insurance appeal. We're currently still fighting. MM or Navigator, it shouldn't matter. It's just words.
     
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  3. Mama Belle

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    Oh crap. How much more are we talking about? Sounds like I better come up with a plan B also.
     
  4. Jana

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    In May of 2007, our Chief of Peds Endo submitted a letter of necessity to Tricare (North) stating that our son needed Medtronic's CGMS because he was subject to episodes of severe hypoglycemia and suffered from hypoglycemia unawareness. They approved us under DM right away, and they have paid for sensors for one year...so far. We were the first people to get an approval here. Since then they have approved other patients in our area for a Guardian system but not the sensors. Many families around here are having to pay for their own sensors, and we expect that we will have to start paying for ours soon. If you really want a CGMS, keep trying. See if you can get a Chief of Peds, Chief of Endo or Peds Endo on your side.
     
  5. roo'smom

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    We are in the process of trying to get Tricare to cover a Navigator for our 5 yo dd. Our endo is doing all of the paperwork for us. He has gotten the Guardian covered for a couple of his patients, but has not tried for a Navigator or a Dex. We would be the first. I think a lot of it has to do w/ what region you are in. We are Tricare north (kind of odd, b/c we live in VA!). From what I have heard it is difficult to get things approved out in CA. That is where dd was diagnosed and we had a hard time getting her on a pump there, so we decided to wait until we moved here. They wanted 3 months worth of bg logs (not a problem) and other documentation in CA. When we got here I had everything ready to go, expecting the big fight. All I did was go to her first endo apt, told him we wanted her on a pump, and that was it. I agree w/ what others have said - if you haven't already, get your endo involved. I think they give the info that comes from the MD more "clout" than from a parent. Not necessarily right, but just how it is. I will keep you updated on our situation and pass along any helpful info. Good luck and I hope it works out for you in the end!
     
  6. bflohockeymom

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    That's dumb... what's the point of the unit without the sensors???? If it's a medical necessity they should cover it all. I hope they don't start charging you!!!
     
  7. Twinklet

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    Thanks for all the replies! We had no problem getting a pump here, but the CGMS was definitely an issue. Another hurdle is that we are in a location with no military hospital, so we see all civilians for care. That makes it difficult. I may see if I can contact someone at the Peds Clinic on the Presidio (which is staffed with civilian Pediatricians) to help us out.

    MamaBelle, I nearly fainted when I got the price list yesterday:

    Receiver and Transmitter: $1250 (BUT it uses batteries and does not have to be replaced yearly). Cozmo customers get it for $750 off now.

    Here's the kicker: A box of 6 sensors is $550!!!! That's $92 per sensor! Totally ridiculous.

    I could tell our rep was a little embarrassed to tell me the price b/c he knows that I know how much the others are.

    I absolutely love this Navigator, but we may look at MM or Dexcom after the study. $550 a month for sensors is completely absurd IMO; that's more than twice what MM sensors cost!

    Well, I'm going to ping Tricare again this fall. The study doctor said he always sends a "strongly worded letter" to participant's insurance companies with his pre- and post-CGMS data to argue for coverage. I hope that will help, too!

    And Lanae, thanks for all the info you sent me regarding how to fight insurance companies! I printed it and will use it as well.
     
  8. czardoust

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    i tried PMing you but my old PC is acting up. how did you get on the study for the free cgms? we have tricare south, they dont approve the cgms either, we tried.
     
  9. Twinklet

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    We have 2 large university hospitals near us, and both do research and have large Endo clinics. I knew both were TrialNet centers, too. So I called their Endo clinic and asked if they were recruiting volunteers for any diabetes research projects and they connected me with that department. I then heard about the CGMS study and signed up!
     
  10. Lisa P.

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    Do you know what the issue is? Is it experimental because it hasn't been FDA stamped for under 18? Maybe you can find examples of other things without FDA stamp that are covered (e.g. I think Lantus isn't officially o.k.'d for toddlers, but our insurance covers it. Of course, maybe it's best not to point that out to them!). Or is it the technology itself is not something they feel is essential to cover (in which case arguing the danger of the lows would be a good way to go). Of course, you don't want to throw good time after bad, developing your case, if they have already made up their minds. Ugh, I feel for you, what a hassle.
     
  11. piratelight

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    We were denied the Guardian earlier this year by Tricare North. We were then able to do a trial with the Dexocom through Yale where we bought 4 sensors and they gave us the system to use for the duration of the sensors. With the Guardian MM submitted initially and we had to do all the appeals etc. While on the trial with Dexcom they called and of course tried to seel us their system. They would do all the paperwork including appeals if necessary so we decided what did we have to lose. We were happy with the trial and really felt that any CGMS was better than no CGMS. We were approved by Tricare North within a few weeks for the Dexcom and it was at our door this past Monday and we started with it first thing Tuesday morning. I wish that I had some tips, I don't. I don't know if Hunter ending up with and ambulance ride to the hospital a few weeks ago tipped the scales or not. One person involved in the process who I spoke to stated a lot of times it depends on teh information that is initially submitted and said nothing more that would help. Good luck to all the Tricare peeps out there....there is hope.
     

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