Insurance - replacement mask

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Insurance - replacement mask

Post by bmflyer » Tue Nov 23, 2021 9:35 am

I have health insurance and was wondering if they typically cover replacement masks. I called my insurance provider (Capital Blue) but I had trouble getting a straight answer. She had said about getting a preauthorization from my doctor. I'm currently not really seeing a doctor right now.

My thinking is that I have to meet my deductible first before Capital Blue will cover it. Does anyone else have Capital Blue and goes through them for mask/hose/filter replacements?

It would be much easier to just by this from but it looks like I need a prescription simply for a new mask.

Thank you.

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Re: Insurance - replacement mask

Post by ups4 » Tue Nov 23, 2021 10:15 am

Many times you can find better deals through online vendors...even Amazon. I get my replacement cushions from Amazon and they're much cheaper than going through insurance and dealing with my DME.

Now, as far as I know, you can't buy the whole mask without a prescription. However, you can buy all the pieces required and "assemble" it yourself. Once you have the frame, headgear, and cushions, most likely all you'll need to worry about is replacing the cushions every so often.
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Re: Insurance - replacement mask

Post by Pugsy » Tue Nov 23, 2021 11:11 am

Complete mask package purchases do typically require a RX to be on file with the seller but if one shops around a bit they can often find some sellers who will sell a complete mask package and not care if someone sends in a copy of their RX.

Replacement parts ....don't require a RX at all.

Now as to insurance reimbursement for either a complete mask package...original RX for cpap and/or supplies is usually sufficient. The exception being if the original RX was limited in some fashion or other.

Insurance will normally consider replacement masks (total packaging) and/or replacement parts as a covered expense and pay for the item per the insurance contract. Most insurance companies use the same replacement allowance that Medicare uses for what Medicare approves or covers. Not all do but most do and each person has to be familiar with their own insurance evidence of coverage as it pertains to their policy. Not all policies are the same even within the same umbrella of companies. Example...Blue Cross/Blue Shield is state by state for one thing and even within the same state BC/BS has a large number of different plans so each plan has to be looked at individually for exact coverage.

At any rate...any deductibles per the insurance contract will apply first before the insurance actually pays for something.
Note the "approved amount" and not necessarily the billed amount is what gets applied to any deductible requirements.
So people do have to "meet their deductible" first. Most understand this fact.
If deductibles are high and no where near being met then most of the time it is just easier to forgo insurance involvement and pay out of well as often less costly.
Most online suppliers (like don't want the hassle of filing insurance anyway so they won't file insurance in lieu of payment but there are some online retailers of cpap supplies who will work with people and file insurance for them and wait for insurance to pay.
We are nearing the end of most insurance companies physical year and any deductibles needed to be met will probably be reset in January 2022.

Now as to this question..
bmflyer wrote:
Tue Nov 23, 2021 9:35 am
I have health insurance and was wondering if they typically cover replacement masks. I called my insurance provider (Capital Blue) but I had trouble getting a straight answer.
Yes, most insurance companies will pay for or allow the costs for a total mask package or any replacement parts.
Most use Medicare guidelines (see image below for what medicare deems their replacement allowance).
Your insurance company will have their stated guidelines within the evidence of coverage for your plan. The person you talked to...quite frankly probably the low man on the totem pole and either didn't know this or didn't care to figure it out.
If you wish to pursue insurance paying for cpap stuff and you can't get a clear cut answer to your questions you need to ask to speak to someone higher up on the totem pole.

Any doctor, NP, PA can authorize a RX for cpap stuff. It doesn't have to be a sleep doctor or your original prescribing doctor.
If you have a PCP who is aware of your cpap use that PCP can generate a RX for a total mask package or other cpap supplies.
Most online suppliers (like who need or require a RX for a total mask package will even help you get a RX if you don't have a copy of the RX handy. They will contact any doctor you choose and get the RX from them for you...and then you can buy a total mask package or whatever you want that might require a RX to be on file.

You may have to dig deep in your evidence of coverage documentation for the actual contractual obligations for your insurance plan. Capital Blue seems to be some sort of division or plan from BlueCross/BlueShield. You should be able to go online and look up the specific "evidence of coverage" documents if you can't find them in your on hand documents.
From a quick look at does appear that this might be a Medicare Advantage plan of some sort.
Are you medicare age? ... tage-plans
If this is indeed what you have then the Medicare guidelines below will apply to you. Medicare Advantage plans all start with what Medicare normally approves.

Medicare replacement allowance guidelines below.

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Re: Insurance - replacement mask

Post by bmflyer » Tue Nov 23, 2021 10:16 pm

Thank you so much for the replies. Some great info. I haven't quite hit my deductible yet so makes sense for me right now to just pay for the replacement parts. What's funny is that I can purchase the replacement parts and "build" my mask for $20 less than purchasing the assembled mask. :)