At the beginning of this year, my insurance company (Regence) decided to stop using Byram Healthcare as their DME supplier and switched over to their pharmacy program. I was not informed of this change at all. If a letter was sent, I certainly never got it and there is no record of a notification on the Regence website…but I digress.
Originally, I would place an order through Byram and they would deliver it to my home while billing insurance. After insurance, a 3 month supply of Dexcom G6 sensors and a transmitter would cost me about $150. A 3 month supply of my Tandem TSlim cartridges and supplies costs about the same. So, overall, I paid roughly $300/3mo for my diabetes supplies, usually at once because I have to set aside what I can from each paycheck. It is still very expensive, but it is an amount I can manage if I budget.
Now that Regence has moved to their new pharmacy system, things have changed drastically. A new order of a 3 month supply of Dexcom sensors and the transmitter now costs over $800…a five fold increase in price. I only found out about the Dexcom price tag after placing an order through my endocrinologist and main pharmacy (Walgreens). Since the office has not put in an order for Tandem as of yet, I do not know the prices…but I am expecting a similar price hike.
I need some help finding resources to help me pay for these supplies or otherwise lower the costs so that I can afford these supplies. I have been using my Tslim for over 10 years, and the Dexcom almost as long. I know no other way to manage my condition and cannot go without them.
If more information helps, I am an Oregon resident, on Regence Insurance (Legacy Silver Plan) through the healthcare marketplace exchange, and am able to “make a life change” at any time in order to gain access to a special enrollment period. My insurance covers 50% of the costs for
I can answer any other questions if it helps me get the resources I need. If anyone has any experience with this, I’d be very grateful for the assistance. I have about a months supply of CGM and Pump supplies left. I won’t go into detail how dire my situation is right now, as I don’t like playing that card, but time is…of the essence here.
A few thoughts - you’ve been doing this for a while but maybe you missed something (I hope that’s the case):
Occasionally something gets processed incorrectly so you get charged more than you should; so if you haven’t done so already ask your insurance to check the charges to make sure they’re correct, especially if their math differs from plan documents.
Do you have a deductible you have to meet before the coverage pricing kicks in?
Sometimes it’s a matter of having a pre-auth in place - now and then when I place an order my supplier lets me know they need one, and in my experience they’ve done the legwork themselves of contacting my physician for what she needs to submit. Maybe it slipped through the cracks for you.
I’ve found my device reps to be very knowledgeable about plans and suppliers. They may know of other suppliers and might even be able to tell if your order was processed correctly based on their experience with your insurer.
Disclaimer: Log in to the Regence web site and verify everything I’m about to say applies to your health plan using the Evidence of Coverage and Formulary documents.
Some more googling shows most of the silver plans are charging 30% coinsurance for DME. Does this match your docs? I found a “2023 metallic plan formulary” from Regence that has dexcom listed as a Tier 4 “drug” aka the Brand Name tier.
I cannot for the life of me find a table that says “What you will pay” and Tier 4. I’m a glass half empty person so using the summary of benefits table the listing for Brand Name Drugs says 50% coinsurance. Please check your docs and tell us what you have to pay for Tier 4. I really hope your insurance didn’t do something as terrible as changing your coinsurance from 30% to 50%.
Try calling or logging in to the Regence mail order pharmacy and getting an estimate. If they are overpriced call other in network pharmacies to find the lowest price. Also check to see if Byram and the other DME suppliers are considered “in network” pharmacies.
You are right that this is a material change to the health plan so this would qualify you to pick a new one if the total cost of another plan plus what you pay for supplies would be less. Be ready to jump through an extra hoop of fire to justify the change. Let us know if you end up going this route and we can come up with suggestions to help you pick a good plan.
Thanks for naming your insurance. It was a huge help for me trying to answer your question.
For tier 4 I have to pay 50% of the costs unfortunately. I don’t think that has changed between this year and last year. I have the same health plan as before. Is there a way to check and see if that is what they did?
Byram is also no longer covered as an option. I don’t have any experience with any other DME’s. I think Byram is the standard out here as it was the provider for Kaiser a couple years back while I was under that insurance.
I have Edgepark and have used them almost exclusively for ages, with only one problem a couple of years ago. There have been some discussions on the forum re different suppliers and opinions vary on them so I think you have to see how one works for you. You can check your provider directory for a list of suppliers, or ask your device rep for recommendations.
So sorry to hear about this change - can insurers really change their benefits once the plan year has started? I would think what they have written in their policy for the year would be set. That’s a rhetorical question and I don’t mean to get off track with another discussion unless it’s germane to what @MattIngham13 originally asked.
Matthew, I have a sealed box of Tandem infusion sets left over from when I switched to Omnipod a few months ago. ifert you’re interested, click on my name above and send me a private message with your address and I’ll send them - hopefully by the weekend.
I’m sorry this has happened to you. Definitely get a price from Regence’s mail order pharmacy company for your Dexcom supplies. The coinsurance % may have increased but the contracted price may be lower so the difference you have to pay might not be so bad.
For your pump supplies here is a list of DME suppliers (in alphabetical order) that may sell Tandem supplies. You will have to check with Regence to see if any are in network.
Advanced Diabetes Supply
Byram
CCSMed
Diabetes Supply Center of the Midland
Edgepark
Edwards
Healthy Living Medical Supplies
Minipharmacy
Pinnacle
Solara
US Med
Wellstart Medical
Tandem pays for a service that tracks insurance coverage of their products. If none of the companies above are in network or don’t pass your requirements give Tandem customer service a call.
Unfortunately they can do almost whatever they want it seems.
I would very much appreciate the help! For some reason I cannot find a way to message you by viewing your profile. I’m sorry, I am brand new to the website.
try it again @MattIngham13 the reason DM was locked out is because you are a new user. You should be able to DM now, click the person’s profile pic, click message.
Insurance companies can change formulary and preferred suppliers without telling you. Plans can change at the beginning of the plan year and can include restrictions, copays, and out-of-pocket or deductible amounts at the beginning of the plan year. Sometimes a more expensive plan saves money, if you know your deductible limits and the plan out of pocket.
sometimes the higher “expense” is just until you meet your deductible. the way all plans work now (in my opinion) is you are forced to pay more, sooner, up to your deductible limit, and then the plan starts covering. having a plan for this shift in cash flow is imperative to you because without a plan change, this will happen to you every year.
if your plan simply cant cover your supplies, and you cant get coupons, plan changes, have exhausted all your appeal attempts, or other long term strategies in place, then this problem is something that a few donated supplies will not solve - but good luck I hope you find a way.
Hi Matthew, I’ve struggled with similar insurance coverage/cost issues many times. The good news is the insulin & CGM manufacturers (incl. Dexcom) offer savings programs. Here’s the link for Dexcom: Dexcom CGM Cost Savings and Coupons | Dexcom | Dexcom
It might be easier to call Dexcom, explain the situation and ask for help rather than navigating the website yourself- it’s up to you.
I take MDI rather than the pump, and all of the insulin manufacturers are also offering savings programs. JDRF just put out this explanatory memo:
There’s a good chance the pump manufacturers also offer savings programs to offset high co-pay costs. Call your pump manufacturer and ask.
We shouldn’t have to do all of this extra legwork when we’re already struggling to manage such a serious chronic disease, but we do here in the USA. The good news is that help is available- you just have to make the effort.
Hi Matthew, Circling back to see if the info on Dexcom savings was any help ? Over the years, I’ve learned it’s sometimes cheaper to get T1D meds/supplies by paying cash and using the manufacturer savings voucher, instead of insurance. I just called Dexcom and they offer savings vouchers for cash pay and commercially insured patients. I hope this will help ! -Joanne
Hi Mathew, I also have extra supplies a box of autosoft xc and I may have some cartridges as well. My daughter started on the pump last Nov. and we had to change her sites to AutoSoft 30. I was once given extra supplies from a kind lady on this website and I would like to pay it forward. If you are interested send me your address.
The box is open but the sites are sealed and have never been opened.
Matthew I wanted to follow up with you to see how things were going. Was your insurance plan’s mail order pharmacy any less than the local pharmacy? Are you still thinking of changing insurance plans to get better coverage?
