I just received notification that my insurer will require prior authorization for Dexcom / CGM usage ON AN ANNUAL BASIS starting January 1, 2022. I realize there are lots of things to get frustrated about in our lives today, but I am really steaming at this new requirement. I could maybe see prior authorization to show that you are type 1 or type 2 requiring CGM ONE TIME, but what a damn waste of time, money, and resources for me, my physician, AND my insurer. What’s their goal here?
What would be an appropriate public awareness campaign? Would it make sense to tweet @ BCBSMA as well as the administrator signing the letter? I realize this is probably a losing battle, but I’d like to do something that feels like I’m taking back a bit of control and at least educating others on this lunacy. Thanks for your thoughts - Jessica
To put up roadblocks that reduce the number of people that will go through them. They will coach it under some data showing that people are getting the CGM’s and not using them. So why should they pay for them. And if they made that data public when they make these decisions, perhaps we could sympathize with them. But to make a person with a chronic condition that isn’t going away get prior authorization for their insulin, pumps and supplies seems quite cruel from the outside.
just checked mine, (humanna) and the prior authorization lasts 2 years for me. ( I think it was a year when I had blue cross) The reason they require those to be frequently renewed is that there may be ,in the year or 2, an alternative that is less expensive that comes along, and if there is they would want you to switch to that. This is mainly likely in prescription pills etc that come off of patent and become available in generic, (also agreements on prices that the insurer will negotiate yearly with the drug companies, For a while I was changing test strip brands once a year because of that) I think insurance companies just do a blanket order for all rx’s that are under prior authorization to renew after a set time rather than only those that they know will be subject to change
I think my insurance has always required annual prior authorization. For sure for the pump, but I think also for Dexcom. It isn’t a big deal because they (or the pharmacy) contact my doctor directly so I don’t have to be involved. But yes, what indeed is the point? Don’t doctors and their staff have enough to do without doing clerical work?!
BTW (this topic popped up for me again for some reason), I recently got word that BCBS MA rescinded their annual prior approval policy for Dexcom! I did send them an email at the end of last year letting them know why I thought their policy was a waste of time and others must have done the same! Score one for the good guys…
@jim26 I have not – should I just call BCBS to ask? I’m not sure what this even entails? I know people who pump are comfortable making this evaluation. Would pharmacy be with my local pharmacy or mail order (Express Scripts)? (And it does seem like Express Scripts would be a lot less hassle!) Thanks so much!
@JessicaD Sorry you’re having the issue with BCBS! Unless you’re part of the insurance field, I’d recommend calling Dexcom or one of the major suppliers to work the insurance angle for you. They’ve been down the road many times and I think know the magic words to use with each insurance company to get it approved and they have incentive to get you on/keep you on the Dexcom product…money in their pocket. We mere mortals…uh, users…may understand the need but not the “how” of getting it done.
It only gets worse when you go on Medicare… My DME in only allowed to send me a one month supply of Dexcom sensors (per Medicare). One nice thing about Mediare is between my private insurance (BCBS Fed) and Medicare, I don’t have any copays for most of my diabetic supplies (after satisfying my small deductable.
Medicare also requires Type 1’s to get a C-Peptide Test (to verify you are ‘really’ a T1 diabetic.) After 30 years of living on insulin, I am pretty sure I am a T1 My C-Peptide results did indicate I am T1
Indeed; I have that in progress, 3 years before I require it. Everyone should sort this out before reaching 65. At present I couldn’t get an endo appointment until August, but PCPs can order the test too. If you are in the US do this.
@ChrisAlb I am on Medicare and BCBS and I get sent my sensors every 90 days. I use ADS, but a few other companies do the same thing. I gather some of the suppliers go ahead and send it and just bill Medicare every 30 days, but some are not willing too.
Does anyone know if Medicare requires an ‘annual’ C-Peptide test? I did some searching and did not see any reference to a yearly test requirement. Thanks
@ChrisAlb I believe they require a past test and if you don’t have that then you have to get one done. But those results are in my records. I had one years ago before I was on Medicare along with an antibody test and was not asked to do one again when I went on Medicare or after.
But I also think an endo or the prescribing Dr would be reviewing cgms results and would question if person getting RX was not providing/reviewing data periodically.
My C-Peptide results did indicate I am T1