FDA CPAP Mask RX-only Enforcement Poll

[ChicagoGranny]

Will insurance pay for something that does not require a prescription?

The prices will go way down if a prescription is no longer required and a DME license is not needed to be a seller. Overall costs in the system will drop significantly. (cpap.com might not survive. )

[Wulfman...]

Will insurance pay for something that does not require a prescription? I agree that it seems stupid to require a prescription, but I have a bad feeling that removing that requirement would suddenly cancel all insurance coverage for these supplies. My cardiologist told me to get a blood pressure monitor, but I had to pay out of pocket since it did not require a prescription.

Also, I have one medication that is available OTC or prescription. I get it free with insurance if I have a prescription. Full price if I go with OTC.

Be careful what you ask for.

I will if there's an "insurance billing code" for it. They did before the crackdown in 2009. Masks did have and still do have insurance billing codes. Nothing has changed in that regard.

viewtopic.php?f=1&t=47518&p=429546&hili ... ed#p429546

We own a couple of blood pressure monitors. They're relatively inexpensive......$40 - $60. If they were to require a prescription, the costs would escalate. In my opinion, if the CPAP masks weren't categorized as "medical", they would only cost about $20 or less. There's nothing to them that would account for their outrageous costs......other than their classification. Consider how many are given away to the DMEs and other suppliers as promotional and bonus "freebies".


Den

.

[jencat824]

Den,

I think at the time there was an insurance billing code because it was a prescription item, the FDA/DEA just wasn't enforcing it for internet purchases. Once the FDA/DEA made it known that a RX must be on file if you sold it, then most online suppliers began to require that RX. If I have this right (and I could be wrong), B&M DME's still received RX's from Drs. but online stores were fairly new to the business & weren't requiring a RX for the mask & supplies, just the machine. When the FDA/DEA got into investigating these businesses, they began to require the RX to protect themselves in case of a DEA audit. Again, I might be wrong, but I think this is how it happened. It also happened around the time my Dr. didn't want to give me a RX (long story, not relevant here).

As for zoocrew's remark about 'be careful what you ask for' there is a lot of truth there. Think in terms of allergy medicine. If you take it every day & it costs $25 for 30 pills OTC, but your insurance copay for RX is $10 for 30 pills, well what would you rather pay. Annually that is $300 OTC or $120 RX. This figure works out differently for those with insurance that pays well for RX and those whose insurance doesn't pay well if at all. What you wish for depends on your insurance coverage for the item in question. Just something to think about.

Jen

[ChicagoGranny]

Think in terms of allergy medicine. If you take it every day & it costs $25 for 30 pills OTC

I don't know any allergy pills that are that expensive. A case made with an unlikely hypothetical is not a case.

[Wulfman...]

Den,

I think at the time there was an insurance billing code because it was a prescription item, the FDA/DEA just wasn't enforcing it for internet purchases. Once the FDA/DEA made it known that a RX must be on file if you sold it, then most online suppliers began to require that RX. If I have this right (and I could be wrong), B&M DME's still received RX's from Drs. but online stores were fairly new to the business & weren't requiring a RX for the mask & supplies, just the machine. When the FDA/DEA got into investigating these businesses, they began to require the RX to protect themselves in case of a DEA audit. Again, I might be wrong, but I think this is how it happened. It also happened around the time my Dr. didn't want to give me a RX (long story, not relevant here).

As for zoocrew's remark about 'be careful what you ask for' there is a lot of truth there. Think in terms of allergy medicine. If you take it every day & it costs $25 for 30 pills OTC, but your insurance copay for RX is $10 for 30 pills, well what would you rather pay. Annually that is $300 OTC or $120 RX. This figure works out differently for those with insurance that pays well for RX and those whose insurance doesn't pay well if at all. What you wish for depends on your insurance coverage for the item in question. Just something to think about.

Jen

You jogged my memory...... (about something humorous)
My original Rx for my machine was so poorly written, that it mentions NOTHING about ANY kind of mask. When I asked my insurance provider about it and being able to order one, I asked them "What am I supposed to do......stick the hose in my mouth?" They kind of chuckled and agreed that it would be kind of hard to do the therapy without one.


Den

.

[jencat824]

Think in terms of allergy medicine. If you take it every day & it costs $25 for 30 pills OTC

I don't know any allergy pills that are that expensive. A case made with an unlikely hypothetical is not a case.

Sorry, I was a little off on the exact price of the med I had in mind, Zyrtec 10mg, 25 pills, $20.49. This makes it $24.57/30/days, $294.84/yr. I would still take the $10/month copay $120/yr pricing.

I made this case because every time my basic allergy med (RX) goes OTC my allergist changes me to another RX med because he feels the OTC pricing encourages his patients to skip meds. Now I would pay ANY price for my allergy med, I live in the Ohio River Valley & we practically invented nasal allergies. We are rated as the worst place to live for allergy sufferers & Drs. tell newcomers 'welcome to allergy country'.

Data on pricing from Walgreens website. I would post a link but can't do that from my tablet.

Jen

[palerider]

Sorry, I was a little off on the exact price of the med I had in mind, Zyrtec 10mg, 25 pills, $20.49. This makes it $24.57/30/days, $294.84/yr. I would still take the $10/month copay $120/yr pricing.

or you can get the costco version for about 12$ for 365 pills.

I guess one comes up one short on leap years. *lol*

[ChicagoGranny]

Zyrtec 10mg, 25 pills, $20.49. This makes it $24.57/30/days, $294.84/yr. I would still take the $10/month copay $120/yr pricing.

Oh my goodness! I hope you are not paying those prices. Like PailRider says you can get a year supply for $12 at Costco.

The generic name is ceterizine. If you don't have a Costco membership, try Amazon. Plenty of cheap options, http://www.amazon.com/s/ref=nb_sb_ss_sc ... Caps%2C292

[msla]

Sorry, I was a little off on the exact price of the med I had in mind, Zyrtec 10mg, 25 pills, $20.49. This makes it $24.57/30/days, $294.84/yr. I would still take the $10/month copay $120/yr pricing.

or you can get the costco version for about 12$ for 365 pills.

I guess one comes up one short on leap years. *lol*

My favorite is the quarterly delivery of 90 pills.

[LSAT]

Zyrtec 10mg, 25 pills, $20.49. This makes it $24.57/30/days, $294.84/yr. I would still take the $10/month copay $120/yr pricing.

Oh my goodness! I hope you are not paying those prices. Like PailRider says you can get a year supply for $12 at Costco.

The generic name is ceterizine. If you don't have a Costco membership, try Amazon. Plenty of cheap options, http://www.amazon.com/s/ref=nb_sb_ss_sc ... Caps%2C292

FYI...At Costco, you do not need a membership to purchase from the pharmacy or optical dept.

[palerider]

Zyrtec 10mg, 25 pills, $20.49. This makes it $24.57/30/days, $294.84/yr. I would still take the $10/month copay $120/yr pricing.

Oh my goodness! I hope you are not paying those prices. Like PailRider says you can get a year supply for $12 at Costco.

The generic name is ceterizine. If you don't have a Costco membership, try Amazon. Plenty of cheap options, http://www.amazon.com/s/ref=nb_sb_ss_sc ... Caps%2C292

FYI...At Costco, you do not need a membership to purchase from the pharmacy or optical dept.

true, but I'm not sure that counts for OTC items. for Rxes, yes, ... and costco is often the cheapest place for rx drugs.

[ChicagoGranny]

FYI...At Costco, you do not need a membership to purchase from the pharmacy or optical dept.

I think that is for prescription items only. Zyrtec is OTC.

Is there an echo in an empty pail?

[palerider]

FYI...At Costco, you do not need a membership to purchase from the pharmacy or optical dept.

I think that is for prescription items only. Zyrtec is OTC.

Is there an echo in an empty pail?

I dunno, grumpy, are you cutting and pasting off my answers again?

[chunkyfrog]

Costco is very competitive on hearing aids.
More than enough to balance out the membership.

[library lady]

As someone who was diagnosed in late January of this year, I acquired my PRS1 560 with no knowledge whatsoever about what I should get. I knew my RX specified the details of what I needed. It didn’t occur to me to research the machines, etc. My DME tech took lots of time to acquaint me with the machine after I chose the PRS1 over the S9 Autoset….because the controls appeared to be easier for me to operate.. knob- and hose-wise. It has turned out to be a good machine for me, and I’ve since learned that my DME only offers full-data machines so I wouldn’t have gone wrong with my choice in that regard.

It was only after struggling with mask issues that I came to this forum a few days after I started using the machine on Feb. 3. I had not been able to get more than 3 hrs of sleep and my AHI, according to the machine readout was 23 on my second night. I learned how to adjust the mask with the mask fit feature, about mask liners, Sleepyhead and many other things.

My take for DMEs would be to offer a tour of their facility’s products to all new apnea patients so that they know what’s available – liners, hose buddy, etc. and why they might be needed for some people. I was told nothing about accessories like these and didn’t know they existed until I came to this forum. Once I learned about liners, I googled to find out what’s available and tried some of each brand to learn which worked best for solving my mask issues. They were a game changer for me!

I also think that DMEs need to have at least one staff person who actually uses CPAP… maybe several so that at least one is on duty whenever the office is open, and one can be a rover to deliver equipment and do home assistance.
These two things are probably the best things to do to ensure that patients, especially new patients, can get the help they need. I believe it is the lack of these elements that prevents many who have been diagnosed with apnea from continuing with cpap.