Advocate for insurer to support CGM and insulin pump use as a T1D

My health insurance is with American Foreign Service Protective Association/ Aetna. I’m anticipating a visit with my endo in Nov. (new patient) and I want to know where I can find resources about advocating for my insurer to consider supporting my use of a CGM and/ or insulin pump to better control my blood sugar. Where can I find these resources, please?

Where are you located - or perhaps I should ask, where will you be receiving care? My understanding was that most insurers in the US cover pumos and CGMs, although perhaps not all brands. I had Aetna many years ago and my supplies wete covered: since American Foreign Service Protective Association/ is associated with Aetna, Aetna may be the place to start.

The endo I’m seeing is in Carlisle, PA and included (in network) with Aetna. I couldn’t find anything in Aetna’s info for diabetics except for their Livongo initiative for T2Ds and their list of covered insulins. Thanks for responding!

Hi @n3bdyson welcome. After a doctor writes a script, the insurance co then approves or denies that request. It falls back to you to start an appeal based on the denial. If the appeal gets denied again you have some choices under the “affordable care act”, but I’m my limited observations a second denial is rare for pumps and CGM. The ADA link here might be a good place to start but in my opinion , it seems a little early to drag out the howitzer. Good luck!

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Thanks, Joe. I suspected that I’m going to have to play the deny - appeal process with the insurance company so I appreciate you sharing this with me.

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I hope you will be pleasantly surprised at the process. When I got my first pump about 30 years ago your doctor had to document medical necessity for it (and perhaps the CGM as well). I think coverage is now more commonplace since the benefits are so widely understood. Your doctor may have to provide certain documentation and go through some additional authorization processes, but if your doctor has been working with Type1 patients for a while they should know what to do.
Is there a reason you are expecting problems?

Aetna’s Livongo program seems to be geared to addressing the needs of T2Ds more than T1Ds and I couldn’t find any information about their provision of CGMs or pumps, just a list of covered insulin types.
Anyway, I’m hoping for a good outcome. I’ll be sure to post after my visit in Nov. 2023

@n3bdyson Welcome Michael to the JDRF TypeOneNation Community Forum!

The place to begin is with your insurance company and know which devices are “preferred” in its formulary, do your research and try to determine what best fits your lifestyle and needs. If a particular CGM or infusion pump arrears to be good for you, get in touch with a service representative for the manufacturer; this service rep can often tell you if the device is favored by your insurer. There is also some good information available for your research under the “Resources” tab at the top of this page.

That said, it is my opinion that a good CGM is the most valuable tool available for effectively managing autoimmune diabetes - insist on that. I don’t know the rules in Pennsylvania, but in Florida insurers must cover CGM prescribed by a physician for people who meet certain requirements - T1D are almost always covered.

Keep in mind that an insulin infusion pump is not magic and not necessarily recommended for all PwD. An informed discussion between you and your physician is necessary. I’ll offer the first question - “why do you need / want a pump?”. Have a response ready for your doctor.

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I have Aetna Medicare Advantage and as a T1 my CGM is covered in full and pump supplies are partially covered with me only paying a small co pay

I’m not sure what T2 coverage might be or if even different
I would call your insurance company. I did that initially and they could share with me about coverage for various supplies. That was helpful when I visited my endo

Excellent information to help me prepare for my meeting with the doctor. Living in Japan for 14 years and finding a new doctor here has been challenging so I appreciate the support!

This information is very helpful. Thanks for responding!

Welcome back from Japan!
Have you thought about which pump you want? It would be good to do some study on the options - Medtronic, Tandem and Omnipod - so you can see if any particular one seems like it would best suit your needs - or if you frankly find one more initially appealing than the others - so you can make an incitement choice rather than having the doctor tell you “Get this one.”

It’s a question of “what do you want your pump to do” isn’t it? The cost — benefit ratio is really something to consider on a fixed income, too. Sounds like the pumps mentioned are the “Big 3” with regard to user experience and support. This is very good to know!

Those are the only 3 available right now in the US. I think there may be others available in Europe but the US has not approved them. I like to read “real user” reviews in addition to the published material. There are lots of comments on this forum alone about Medtronic (Minimed) vs Tandem (TSLIM). People complain more about issues than they praise positives, so don’t get discouraged. And keep in mind one pump or CGM may work better for a person than another.
By the way, do you currently use a CGM? If not I would suggest you start with that and add on a pump later, so you don’t find yourself overwhelmed with technology. That said, Minimed’s CGM only works with its own pumps. Dexcom works with Tandem and Omnipod. There is also Freestyle Libre - it did not work with pumps but if you don’t need that it may be a less expensive option.
Sorry if I’m overwhelming you but these are things you’re going to be discussing with your endo. You may want to do it over time rather than making a decision all in one visit.

@n3bdyson I’m with @joe, probably better to find out what coverage already gets covered by the company (you could try calling and asking first, if you haven’t) before starting the path of a challenge of denial (though it never hurts to be informed of what you might need for that process). As @wadawabbit says, you may be pleasantly surprised and find a script is covered. Find out what’s “preferred” or in the formulary, what requires “pre-approval”, and then worry about needing to fight the system. Best to have the “preferred” list available for the doc up front so you don’t have to re-engage on the script and delay getting the treatment you need.

Your pump and CGM might fall under the heading of Durable Medical Equipment. While you should read the details of your insurance coverage to get an idea what to expect as far as co-pays etc, I suggest you let the device rep work with your insurer to determine your benefits.

ALL of this information is welcome, thank you. I’ve been on a multi-dose insulin regimen since I was diagnosed. My insensitivity to lows and other changes over the last 10-15 years is making me move in the direction of investigating CGMs and pumps. Your observation about being overwhelmed with tech is spot on.

Thanks for sharing your experience with tech and know that I appreciate your counsel.

Yes, I’ve been caught off guard in the past when I received a prescription for an insulin that had previously been approved and subsequently moved to a “less preferred/ not so much covered” category. Thanks for providing your insight. I appreciate it!

REALLY good information about letting the device rep work with my insurance company. I suspect that the combination of my doc, device rep, and insurer working together can make good things happen.

Let’s just say I learned the hard way🤪!