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How to get an insulin pump covered by medical aid: a step-by-step guide

One of our community members, Armand Greyling, wrote to us to explain how to get an insulin pump covered by medical aid. He shared this step-by-step guide.

What all the words mean

Before we begin, let’s start with a few reminders:

Why did you write to the CMS? What was your specific complaint?

My CGM device reached the end of its lifespan in early 2022. I phoned my medical aid, ProfMed, to enquire as to how I should go about having them fund a new one.

I enquired about the details surrounding the approval and found out the agent was
referring to an application sent by my specialist physician requesting approval for
insulin pump therapy.

This application had been sent to ProfMed ever since I joined as a member in 2014, and every year it was declined.

Armand Greyling

But for some reason it was reviewed and approved in February 2022 without anyone informing me of the outcome. So I then enquired whether or not ProfMed would be funding the insulin pump and all monthly consumables in full. I was told that a 30% co-payment would apply on the monthly consumables and that ProfMed would fund 100% of the insulin pump and CGM device.

I proceeded to obtain quotations from pharmacies to obtain the best pricing option in order to fund the treatment and sent same to ProfMed for consideration.

Armand Greyling

Confusing feedback

After many emails back and forth and numerous phone calls, various agents within ProfMed put forward 4 different versions of how the insulin pump and monthly consumables would be

  1. ProfMed will pay 70% of the hardware and 100% of consumables, member is to pay 30% in respect of hardware (liability letter requested from member, but member wished to know the exact amount he would be held liable for);
  2. ProfMed will pay 70% in respect of hardware and monthly consumables overall, and member will be responsible for 30% of the remainder thereof;
  3. ProfMed will pay 70% of CGM transmitter and monthly sensors, member is to pay 30% of transmitter and monthly sensors, Profmed will pay for insulin pump out of funds available in the external prosthesis fund, member to pay any outstanding amount remaining;
  4. ProfMed will pay for insulin pump and monthly consumables out of PMB, member to pay 30% co-payment in respect of the CGM transmitter and monthly sensors.

My complaint mainly revolved around the lack of clarity regarding the funding of all the devices and monthly consumables and the various versions communicated to me.

Armand Greyling

I wanted the CMS to determine if ProfMed were in contravention of the Consumer Protection Act in making misleading representations. However, this fell outside the jurisdiction of the CMS to determine. The primary complaint was to determine whether insulin pump therapy was appropriate treatment in my specific case and if it should be funded by ProfMed in full.

Who and how did you email them?

I lodged a formal complaint of the CMS website:

You are expected to type your entire complaint online, which creates the difficulty that you
could lose your train of thought if your complaint is as lengthy as mine was. I first typed the
whole complaint in a word document and then copy and pasted the entire thing in the space
provided online.

To support my complaint, I submitted all the various authorisation letters provided by
ProfMed concerning the approval and funding of the insulin pump and monthly
consumables, and also all emailed correspondence received from ProfMed’s various
representatives during the course of my enquiry.

Armand Greyling

This was requested by a CMS representative after the complaint was submitted online. They detail the documents which they require to proceed.

What else did you have to do?

I was also contacted via email by one of the legal adjudication officers of the CMS, requesting my most recent blood results indicating my HbA1c, blood glucose monitoring statistics and the motivation which my specialist physician sent to ProfMed for the insulin pump treatment.

How long did it take?

Once the complaint is formally acknowledged for consideration by the CMS, they indicate
that an investigation and ruling can take approximately 120 days (4 months) after they have received all necessary documents from you in order to proceed. And so my case was acknowledged on 31 May 2022 and I obtained a ruling on 25 August 2022.

What tier medical aid are you on?

I’m on ProSecure Savvy Option at ProfMed (mid-tier).

Is your insulin pump and CGM now being covered in full?

Yes! I did need to follow up with the authorisation department to make sure everything is in order, but now everything is sorted and funded in full.

Any other necessary tips for how people can replicate this?

  • Ensure your motivation for insulin pump therapy is drafted and submitted by a medical
    professional who specialises in diabetes treatment.
  • There are certain things you need to know and be able to do before going on an insulin pump, such as being able to count carbs correctly and having data on the behaviour of your glucose levels during the day.
  • The primary finding of the CMS in my case boiled down to the fact that regular insulin treatment was not providing the desired outcomes. The CMS motivated by way of a regulation in the Medical Schemes Act that where prescribed treatment is ineffective, a medical aid must consider and fund alternative treatments where available.
  • Lastly, keep a record of all your correspondence and reference numbers with the medical aid.

Get an insulin pump covered by medical aid

If you’re inspired by how to get an insulin pump covered by medical aid, and want to attempt it for yourself, please CC in all your emails, so that SA Diabetes Advocacy can be support structure on your journey!

What to read next?

What is a CGM? Flash glucose monitoring and CGM: But what exactly is a CGM? What is flash glucose monitoring? And how do you decide what’s best for you? Here’s all you need to know to make an informed decision.

How to get your medical aid to cover the FreeStyle Libre: Search for your medical aid below to find out what you need to do to get your medical aid to cover the FreeStyle Libre (or a portion of your other CGM).

Your options on the Discovery CGM Benefit: There are 3 CGM / flash glucose monitors available in South Africa. Here’s what they are, and how much they cost.

Photos by Sweet Life on Unsplash

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Sweet Life is a registered NPO/PBO (220-984) with a single goal: to improve diabetes in South Africa. We are funded by sponsorships and donations from aligned companies and organisations who believe in our work. We only share information that we believe benefits our community. While some of this information is linked to specific brands, it is not an official endorsement of that brand. We believe in empowering people with diabetes to make the best decisions they can, to live a healthy, happy life with diabetes.