So remember when I forgot to order my Dexcom sensors in time (for the second order in a row)? Yeah, me too.
Turns out that may or may not be an awesome thing! It is potentially a good thing because as Catherine Price at A Sweet Life found out, if I had received a three month supply of sensors I would not be able to return them. And let’s be honest, a three month supply lasts longer than three months.
Now the bad/confusing news.
I did not receive my sensors because my insurance denied them. In the two years I have been using a CGM, they have always gone through my durable medical equipment (DME) coverage. Last year, my insurance added a third party supplier but it was still DME coverage. This time, the third party supplier denied the prescription and said that it needed to go through my prescription benefits.
I didn’t actually know any of that – I just wondered where my sensors were until I called my local Dexcom representative about the G4 Platinum. Love my rep by the way – hi Lori! She asked why I went through my prescription coverage when I was quoted a price through my DME coverage. She actually named the company, which I would prefer not to do here. I mention that only because I had no idea what she was talking about when she mentioned the pharmacy company. It was not until I googled them that I had any idea who they were or what they did.
I feel like I have been waiting forever (in medical years – I think it works like dog years) for the updated version of the Dexcom so I used my lunch break to track down some answers.
- First call: Dexcom. I got more information about the denial. I officially canceled the order because if I was able to resolve the situation, I would rather order the new version than get “3” months of the old.
- Second call: Prescription coverage. Very nice woman who could not explain a single thing about what was going on with my case. Had never even heard of this retail pharmacy I was supposed to place my order through. Put me on hold several times. At one point sighed, “Ay! Dios mio!” under her breath and was quite surprised when I understood her. Told me to keep my happy attitude. Honestly, I try to stay as positive as I can when I am on the phone. I know that the people who I am speaking with are not to blame for the issues. They probably have plenty of people yell at them and I am not going to be one of those people.
- Third call: DME third party supplier. Also had no idea about the retail pharmacy or why my CGM supplies would go through them. I had an estimate from them that I received Monday and they repeated the same estimate at that point. We discussed a payment plan because let’s just say that I am a few dollars away from the full cash price through this plan. They had no idea why my claim was denied last week and referred me to…
- Fourth call: Health insurance provider. Has never heard of the retail pharmacy. I asked if they changed their coverage recently and they said no, that if it was approved by the FDA, it was still covered. They told me to call Dexcom back.
I was keeping notes on all these phone calls and at this point I wrote “START OVER.”
- First call. Dexcom. Awesome representative who was so patient and explained everything to me. I forgot to write down her name, but she was so helpful! She gave me actual name of people who dealt with my case prior to our conversation. We conference-called my pharmacy coverage and she rattled off codes to them to try to figure out what was going on. AND SHE GOT AN ANSWER!!!!
The best we can tell at this point: My sensors ARE covered by my prescription coverage. But not THROUGH my prescription coverage. They use (you guessed it) the previously unknown retail pharmacy.
There are no National Drug Codes (NDC) for Dexcom G4 Platinum. The NDCs are unique identifiers assigned (at least in part) by the FDA. The best I can tell, these codes are helpful for identifying and reporting on products. This makes sense if you consider how similar some product names are to each other.
I may have some of the terms in this next part wrong, but basically a product cannot get/submit for an NDC code until it has been approved. It then takes 3-4 weeks for a code to be assigned to the product.
AND HERE IS WHERE IT GETS COMPLICATED (HA!)
Once the code is established, my prescription coverage could cover the Dexcom G4 Platinum with a simple prescription copay. They could also deny coverage altogether. There is no way of knowing until that magical code exists.
At this point, I COULD also go back to the third party supplier and ask them to process my Dexcom order. In case you skimmed this post (wouldn’t blame you), that cost would be a few dollars shy of the full cash price. A potential (at least) 93% difference in cost. Yup, I think I will wait a few weeks for those magic codes. If the codes don’t work, I haven’t lost anything but time. In the meantime, I am ordering a box of 7+ sensors to hold me over from the mysterious retail pharmacy in a far away land.
In all of this I return to the idea of self advocacy. I know how to make these phone calls and continue to make the calls until I have an answer that I understand. What about those patients who haven’t learned how to do that yet, who would have given up after the first denial? How do we fix that?
Speaking of advocacy, I was profiled yesterday on Diabetes Mine as part of a summit I will be attending next month. You know, in case reading this monster post was not enough for you.