Supply Replacement

I contacted my insurance company (Humana) regarding their schedule for replacing CPAP supplies. Their answer kind of surprised me. They said that they have no set schedule. Instead, if it is "medically necessary" they replace supplies. That does not seem to correspond to anything I read anywhere else.

I am on a high deductible plan and I have met the deductible for the year. That means that all medical expenditures for the rest of the year are "free." My goal is to get the maximum stockpile of supplies for the rest of the year so I can stockpile some for the next year when I pay full out-of-pocket. Any suggestions on a schedule for what I should be asking for? My DME says they do not have an auto-refill policy to just send things so I have to ask each time. You think I could get away with following the standard Medicare schedule?

BCBS of Texas told me they have a contract with each DME that defines the schedule, so I am now talking to them. Looks like pillows/masks and filters every month, mask frames every 3 and headgear and tanks every 6.

My insurance also does CPAP supply replacement as medically necessary, and they would approve it as long as it wasn't excessive. Doesn't make since to me. My DME recommended I use the standard schedule and said there wouldn't be a problem getting it approved at that interval. I'd at least ask for supplies on the Medicare schedule, or slightly faster. You should get away with that no problem. Definitely stock up on supplies this year. And in the future, if you do have to pay out of pocket, shop around...likely online will be cheaper than going through your DME at full price. List prices are quite ridiculous. You may find your mileage on nasal pillows / mask cushions to be quite different than the insurance replacement schedule. I'm surprised how short or how long they last for some folks.

I think DMEs asks for approval ahead of time so they don't sell the patient supplies their insurance won't pay for, so I don't think you are at risk of having to pay full cost if they think its too early. My DME actually sent a claim to my insurance for a mask only three days after I got my first mask (instead of swapping it for free), as they knew they would pay. Thankfully I only pay 20% of my insurance's negotiated amount is quite good (on par with CPAP.com).

I'd try for at least two nasal pillows or one full face cushion a month, one mask with headgear every 3 months (typically not the same month you get a cushion though), one hose every 3 months, one humidifier chamber every 6 months, and a pack of 6 filters for the S9 every 3 or 6 months. My DME dispenses up to three months of mask cushions at one time. I'd only do that if you are happy with your mask though. If you think you may need a second type of mask, it would be a good time to get that (and replacement cushions).

Check if your DME sells headgear separately as in that case you may want more headgear than masks, as the plastic frame doesn't really wear out. Mine doesn't, and says to just get a full mask when the headgear wears out. I checked and my copay for a full mask is less than paying full price online for headgear (plus I get another cushion that way).

The nasal pillows / mask cushions and masks are probably the most important. You'll only want so many replacement hoses and humidifier chambers, and filters are cheap. My DME said to replace the filter on my S9 every 2 weeks, but I checked every 2 weeks and it was still perfectly clean. After 6 weeks I decided I might as well just replace it. Others say they need to replace it often. Pet hair & dust I assume. Best wishes.

Based on your insurance company's response, I would be a little careful on 'stocking up'. Although all they can say is no, I would make sure the DME is pre-authing prior to you taking the supplies home. If the insurance company denies them, you will be stuck pay the sky high prices he DME charges.

I would start with a mask & pillows, along with tubing & an extra water tank for your humidifier. That way, you are covered with an back-up of everything. Then in about Oct, get another refill of pillows & tubing. Try for another entire mask in Dec. This is kinda following the Medicare schedule, but not getting too greedy. If you ask for a set of pillows at the rate of 2-4 a month, they may just deny you, saying you couldn't possibly need that many. I guess you get the idea behind my approach...ask, but don't overask. Also remember if you get a back-up on the most needed items, you have met your goal.

When your high deductible kicks in at the first of the year, if you do run out of something, ordering from cpap.com can save you a bundle over your DME's prices.

Jen