What’s included in your cover?
We’ll pay benefits for:
- Initial insulin pump
- Insulin pump replacement (medically required).
We won’t pay for:
- Insulin pump upgrades or a replacement that isn’t medically required
- An updated model/technology of insulin pump
- Pumps used to administer a drug or pharmaceutical that isn’t insulin.
A summary of insulin pump guidelines
12-month waiting period on a relevant level of hospital cover, before an initial pump can be claimed.
100% covered for pump.
Inpatient: Benefits paid for hospital accommodation and doctors fees as an inpatient.
Outpatient: No benefits payable for facility or doctor’s fees.
Replacement pump (received as an outpatient)
Must be a Teachers Health member with a relevant level of hospital cover for at least 12 months before a replacement pump can be claimed.
Current insulin pump age 0-4 years: covered under manufacturer’s warranty
Current insulin pump age 4-5 years: benefits are prorated. See below (Replacement pump outside of manufacturer’s warranty period)
Current insulin pump age 5+ years: 100% covered for pump. No benefits payable for facility or doctor’s fees.
Note: Benefits are not payable for insulin pump upgrades or a replacement when not medically required.
Replacement pump (received as an inpatient)
100% covered for pump.
Benefits paid for hospital accommodation and doctor’s fees.
Replacement pump outside of manufacturer’s warranty period (received as an outpatient and the current insulin pump age is between years 4 and 5)
Prorated benefit to reflect the age of the pump. You’ll have to pay an out-of-pocket cost for the insulin pump.
For example, if you claim a replacement pump after the current pump is 4 years of age and the pump costs $8,574 then:
$8,574 / 5 = $1,714.80, so we pay a benefit of $6,859.20 and you pay the remaining $1,714.80.
No benefits payable for facility or doctor’s fees.
Your questions answered
Here you’ll find answers to common questions about claiming for insulin pumps.
I am about to start insulin pump therapy – can I claim for this?
- As an outpatient: Insulin pump therapy is typically performed as an outpatient service. We’ll pay 100% of the cost of the insulin pump for those listed on the Australian Government Prostheses List. Your treating practitioner must complete the AHSA Initial Pump Funding Application Form – Initial Pump Therapy before the pump is supplied.
- As an inpatient: If you’re admitted to hospital to start insulin pump therapy, you’ll be covered 100% for the insulin pump and hospital accommodation costs. The hospital is required to complete the Type C hospital certification as per legislation. Please note that education is not a valid reason for hospitalisation and we may ask for additional info to verify the reasons for hospitalisation.
Am I eligible to claim for a replacement insulin pump?
If you’ve continuously had either Top Hospital (Gold), Mid Classic (Silver Plus), Mid Hospital (Basic Plus) cover for more than five years since your last insulin pump, you’ll be eligible to claim 100% of the insulin pump cost for those listed on the Australian Government Prostheses List.
If this isn’t the case and you’ve only recently joined Teachers Health, you’ll need to be a member with us for a minimum of 12 months on an eligible Hospital cover before a replacement pump outside the manufacturer’s warranty period can be claimed.
The replacement cycle doesn’t reflect the manufacturer’s warranty period which is typically four years – the reasonable life expectancy of an insulin pump is typically five years. If you wish to replace your insulin pump in less than five years, a pro-rata benefit may be available (provided the pump isn’t under warranty).
How do I claim for a replacement insulin pump?
The insulin pump manufacturer will be required to complete the AHSA Insulin Pump Replacement Application Form, to obtain pre-approval from us. This will ensure you are eligible for benefits prior to the insulin pump being supplied.
Can I claim for insulin pump consumables?
Benefits are not payable for insulin pump consumables. Subsidised products may be available through the National Diabetes Services Scheme.
We adhere to a set of guidelines regarding insulin pumps. If you have any further questions, please contact us.