My insurance plan has out of pocket expense where a specialized drug costs $50 for 30 days supply and if its prescribed for 90 days it will become 3x so, $150. When I applied from Dexcom website I could see that my Dexcom G6 transmitter was prescribed for 30 days so it showed $50 as out of pocket for in claims details. Now, I have been prescribed it though Walgreens where they filed the 1 transmitter for 90 days which made my out of pocket to $150. Can the physician change the 1 transmitter supply to 30 days instead of 90 days? This would save me a lot. Please someone let me know if this is possible.
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No, 1 transmitter is intended to last 90 days so a prescription wonāt be written to get one new one every 30 days unfortunately. We are in the same boatā¦prescriptions every 90 days. We would love to have one in reserves but the way the system is designed, the transmitters are hard to get a surplus/stock of unless you want to pay for them in cash out of pocketā¦which I wonāt do.
Also, if youāre getting the Firefly G6 Transmitters shipped to you (The transmitter ID for G6 firefly starts with 8Gxxxx and the transmitter is visually different than the old ones.), you canāt do a transmitter reset on those either as you could previous versions as well as was possible with the G5 transmitters
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You might want to look at what the cost would be to get the Dexcom filled as Durable Medical Equipment (DME) rather than a prescription. That might be cheaper.
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Though all of that could be out the window when the G7 is releasedā¦
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Somehow, my prescription for g6 transmitter is written as a 30 day supply, so Iām paying $30 for it as opposed to my usual 90 day supply at $75. Iām allowed one every 68 days.
But Express Scripts, which manages my prescription benefits, rarely knows what the retail stores are doing. (One of the reasons that I switched from mail order to Walgreens and CVS.)
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@devineni: welcome to FUD! You could try for the durable medical device approach, but normally a co-pay on a US insurance policy for DME is a percentage of the cost; the ācostā of the transmitter is $300 +/- ($295.21 in my case). So if your DME copay is below 50% you will probably be ahead. I should add that previously people here (including me) have reported that the DME suppliers add a further markup to the cost which can make it more than the marked up price for a pharmacy benefit (i.e. something you get from Walsomeone).
My personal experience is that this is a whole load of wasted effort. Add the cost of the sensors; they are $400/shot, but in this case that is a 30 day supply. So, as they say, what you win on the swings you loose on the roundabouts; 90 days of sensors runs at $1249.22 for me, but itās $150 for you; well under a 20% DME copay.
At the end of the day when you start using a CGM you stop worrying about copays because since the introduction of the ACA you will almost certainly meet your āout of pocket maximumā. Over the last few years I havenāt paid anything to anyone after the solstice.
Look at your out of pocket maximum. Do some arithmetic. Most people who have a choice and do that end up going for the absolute cheapest medical insurance they can find that conforms to the ACA. The world for me is a simple addition - cost of premium plus cost of oopmax. Medical expenses for the year, covered. All of them - I havenāt paid anything since January, thanks to the very great expense of fixing a thrice broken collarbone.
You do have a choice. If you are on an employer plan that sucks you can sign up for the ACA, because anyone who gets paid enough can. Just do the math. You can report your employer for being a Richard too.
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My DME sends me my Sensors to support a 30 day period. Actually, Medicare dictates that I only get a 30 day supply (I used to get a 90 day supply before getting on Medicare)
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What about the transmitter? It lasts for 90 days, does that mean you pay for it as DME because it is ādurableā?
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For me , I get a transmitter, 90 day supply of infusion sets and cartridges/needles.
The only item they limit to 30 days is the Dexcom sensors. All of them is first billed to Medicare, and balance to my secondary insurance provider. My DME provides all these items.
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Maybe this is price related? I just got my 90-day supply of sensors from Walmart (so as a prescription item) and the price I paid was $1000. (The ācashā price was $1300, but that includes the PBM kickback apparently; it was marked as āNVTā in Febrary for āNavitusā).
The other items will all run at less than $500 and the US price for any item of diabetic medication/supply is about $300 for a month; the G6 receiver was $250 to me, $300 to Navitus.
Maybe the Medicare/CMS rule is that anything up to $300 (or so) for 90 days (the sensor supply is actually 84 days) is fine, anything over that has to go to 30 days?
For Medicare folks who get their G6 sensors and transmitters as DME, I believe that it is still true that sensors get billed to Medicare every 30 days. However, some of the mail order places will send you one transmitter and 3 boxes of sensors every 90 days. I think that they actually bill Medicare every 30 days but actually send you a 90-day supply.
Who does it this way? US Med (in FL, I think) does this. I think Solara does too ā¦ but that must be a comparatively recent change because they only sent 30 days at a time when I used them. I think that a couple of other mail order places use the 90 day alternative ā¦ but I donāt have a complete list.
This doesnāt necessarily save money because Medicare DME is billed on an 80%/20% basis. A good supplement will cover virtually all of the 20% that Medicare doesnāt, but that is very plan specific
Good luck!
John
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I have transmitters last 105-109 days. Warranty is for 90 days.
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The warranty is complicated - itās for 90-100 days so long as it is used within 150 days of receipt. I just checked my last fill from Walmart and it was for a ā30 dayā supply, which explains why they keep pestering me to refill it (this makes no sense for regular insurance where the insurance company treats it as a 90 day supply.)
The warranty requirement means that in practice a transmitter lasts for less than 90 days; the amount less depends on when you refill the prescription. If you use it for longer than that the next transmitter ends up out of warranty and since the things do fail you can lose a whole 90 day supply if you donāt start a transmitter within 150 days and if fails early.
This almost happened to me last year when I was still using the transmitters based on the manufacture date, not the receive date. Fortunately the transmitter that failed was still in warranty, so I didnāt lose it, but Iāve been doing catch-up since. My last two transmitters lasted 78 then 50 days, but as a result of an early change on the last one I can now use my current one for 90 days.
The actual warranty period after use starts depends on when the last sensor is started; if you start it right at the end of the 90 day period the warranty covers a total of 100 days.
Complicated and silly; they should just give the transmitters away with the sensors. Of course thatās what theyāve decided to doā¦
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This will soon be a moot point when the G7 is released this summer (assuming it passes FDA testing and is approved) The sensor, transmitter, and battery will be a one piece solution that is discarded every 10 days (until someone finds a way to extend itās lifeā¦)
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It depends on how long Dexcom continues G6, and whenTandem pump integrates with G7, and insurance coverageā¦ If lower cost to me, I would consider staying on G6 as long as possible.
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Very interesting info!! Thank you!
I get my supplies from Solara. Iāve had my challenges w them, yet keep learning new tidbits over time.
- Yes, Iād guess about a year ago Medicare moved to billing every 30d. Iād like to keep track closer than that, but too difficult now. ā¦ and their billing every 30 d does not coincide w when I orderā¦ or receive ā¦ best I can tell. Same items are always billed on the same day of each monthā¦. Same amount.
**2. My sensors- biggest headache- solara will issue 90d worth only when the Rx is current for that full period. If 90 d are not left on Rx, theyāll only send 30 or 60 d worth. So it takes more of my time
- Apparently Medicare is allowing only one transmitter to be issued at a time. Hence more of my time needed.
- No such problems w infusion sets. Probably not covered by Medicare.
- I & apparently Medicare do not allow automatic ordering/issuing of supplies. Solara would like to send all possible supplies, and I have limited storage space for suppliesā¦
Iām happy to learn from you all & from Solara on occasion.
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That doesnāt surprise me. The Dexcom warranty requires use of the transmitter within 150 days of receipt. That rule means I canāt get more than one transmitter at once without having a transmitter go out of warranty. Indeed, I canāt even run all transmitters for a full 90 days because sometimes I go over 90 days on a single transmitter then I have to catch back the excess days by running another for less than 90 days.
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Yes. Iām glad you pointed out that aspect. For now I have sufficient cushion so that if one fails I have one in stock.
Yet when G7 arrives, there will be an adjustment period. Hopefully they will endure well.
CRB
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There will indeed; stocking sensors with the G6 basically requires relying on an early fill of monthly prescriptions. The things run for almost exactly 10 days (I think there might be a couple of hours over). So on a 90 day supply it can take longer to build a buffer.
Iām using AndroidAPS with Dexcomās BYODA (Build Your Own Dexcom App) to handle the G6 so, good thought the G7 sounds, I wonāt be moving to it unless Dexcom extend BYODA to the G7.
The transition period basically involves running down the G6 sensor/transmitter stock while ordering but not using G7 stock. Sooner or later we run out of sensors or transmitters and then we make the change. It might be worth trying one G7 first to make sure it isnāt a PoS then swapping back to the existing stocks.
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Thatās not really correct, at least here in the US. It is not the case that the transmitter goes out of warranty 150 days after you receive it. The transmitter warranty is given in the G6 user guide in appendix E.2 on page 290 (https://s3-us-west-2.amazonaws.com/dexcompdf/G6-CGM-Users-Guide.pdf) and it says that the transmitter is warranted for 90 days of service, provided that you start the transmitter within 5 months of receiving it. So if you get a pair of transmitters, start the first one immediately, and start the second one 90 days later, the second transmitter is covered by warranty for a full 90 days.
In my experience, they count 5 months from the day they send it, not from the day I receive it.
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