CGM coverage - a revelation

[docslotnick]

@Pianoplayer7008

Dexcom sent me to Pumps It, which was a flat out denial (going through Caremark, prescription coverage, instead of UHC

I go through PumpsIt now as well. This is the choice of my insurance company. As @Thomas said, Dexcom is out of the picture when the insurance company chooses to go through a DME.

You got denied because Dexcom is not covered under pharmacy insurance. It is through medical insurance.

Go back to PumpsIt. Give them your UHC medical insurance. Tell them to send a CMN to your doc, and when they get it to submit to UHC.

You will get your Dexcom.

[Eric]

What Doc says is absolutely correct. Dex is covered through medical. Just start over and make sure it is sent to the provider for medical insurance. It really should be that easy.

I think this is the mistake someone made when they told you this:

@Pianoplayer7008

“The continuous glucose monitor is covered through Caremark. Therefore, if a member is inquiring about a continuous glucose monitor as a piece of equipment that dispenses glucose that is covered through Caremark.”

[Pianoplayer7008]

@docslotnick

You will get your Dexcom.

Thanks; I am feeling more hopeful today that I’m getting somewhere. PumpsIt did tell me they don’t accept UHC coverage - maybe I should just call and talk to someone else there.

@Eric

I think this is the mistake someone made when they told you this

The worst part is it’s actual wording for on a summary of benefits (not sure if that’s the correct term for the document) listed online on our myuhc account! That’s why I took them at their word. Now I know to dig further. I really haven’t had a lot of experience dealing with insurance hassles; I need some insurance education, haha.

[MM2]

Your last statement (and original post) is the key. If you got that off UHC website, while logged in to YOUR account/member ID, then I think that is correct in stating that dexcom is covered as pharmacy/Caremark.

I know MOST plans cover as DME. But I had Pharmacy coverage with Caremark for several years. I could order from Caremark mail order, or Foundation Care, which could file pharmacy claim. This was not the norm, so often even Caremark employees told me it was not covered, and I had to go up the chain to get someone who could confirm it was covered for my plan. I believe there was a NDC number that was critical to know to get it right.

If your plan is employer based, you could try getting help there. That is how I found out that Foundation Care was valid for me to use. My HR dept knew who to call and get the valid providers. FC got it right every time, and saved me from dealing directly with Caremark.

Your case may be different, and I know how frustrating it can be. Good luck.

[Pianoplayer7008]

@MM2

If your plan is employer based, you could try getting help there.

Thanks! I had asked my husband to help me contact HR at one point (our insurance is through his employer - I’m a stay at home mom), but never followed through. I should try that.