The how to and how much of purchasing pumps and sensors
If I want to buy a Continuous Glucose Monitor (CGM) how much will it cost? Answer: $25
Just kidding. I wish it was that simple (and cheap). For many, this question is very difficult to figure out and people will avoid getting medical devices they want or need because of the complexities. For others, they just go ahead, only to find out that later that they really can’t afford ongoing costs.
This section will show you–
- The process for ordering pumps & sensors
- Where to buy pumps and CGMs
- How to find your upfront and ongoing costs associated with pumps & CGMs
Submitting a claim for a pump or sensor:
After discussing pump or CGM therapy with your provider, the provider then submits a prescription to either a pharmacy or DME (Durable Medical Equipment) company. The prescription must be submitted to whichever supplier your insurance has a contract with. You can call your insurance to find out which suppliers they use. Insurances will usually cover pumps under Durable Medical Equipment (DME) benefit, while CGMs may be a DME or a pharmacy benefit.
The pharmacy or DME company that receives your prescription will submit a claim to your insurance for the pump/sensor you’ve requested for “determination of benefits”…AKA find out if your insurance will cover it. The insurance company will ask for medical chart notes and glucose logs from your provider to see if their insurance requirements for pump or CGM therapy are met.
Each Insurance has criteria as to who will “qualify” for pumps or sensors. Criteria vary greatly from one insurance to another.
Examples of some requirements made by various insurances have included:
- Having >4 blood glucose tests per day for 30 up to 90 days
- Having problematic hypoglycemia
- >2 MD visits/year
- A current A1c
- Duration of Diabetes >6 months
- Type of diabetes, type 1 or type 2
*All of the above vary depending on your particular insurance.
Your insurance company is looking for what they consider a “good” candidate for a pump or CGM. In other words, they don’t want to waste their dollars on a pump or sensor that won’t help control blood sugar. If they see compliance as an issue then they will deny the claim.
If you call your insurance company, they may or may not tell you what the qualifying criteria is. Usually an experienced diabetes provider or DME company knows the criteria for common insurance plans they see and can advise you. If you do meet the insurance criteria, then viola- you get an approval letter and you can start the purchase process.
But how much will I pay?
This is where it gets sticky. There is a number of factors to determining your costs. Below I have outlined a few of the factors, however the best way will be to order your pump or sensor through your DME or pharmacy to get a quote from them.
The multiple factors for determining costs:
- Is my device covered by Pharmacy benefit vs. DME benefit? (pharmacy is usually cheaper)
- Insurance Allowables. What is the maximum allowable amount that the distributor cannot exceed (almost all distributors will charge more than the allowed amount to get fully reimbursed).
- Deductible. How much is left? For large deductibles you will pay more out-of-your-pocket.
- Insurance co-payment. After the deductible is met what is your co-pay as stipulated by your insurance?
Estimating your costs
Below are cost estimates for pumps and sensors. Keep in mind prices might vary a lot depending your insurance coverage allowables. An interactive calculator is coming soon!
*The prices indicated above are cost averages. Individual distributor prices will vary. Your individual cost will depend on your insurance allowables.