What did your insurance pay for prosthetics?

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Marie711
Marie711 Member Posts: 87
edited April 2017 in Employment, Insurance, and Other Financial Issues

I called mine and he could not even give me an exact list. He said they have to cover based on the woman's health and cancer act of 1998. I tried google but I am having trouble finding a list. What is typical? # of bra's, forms, swim forms?? Anything else?

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  • BarredOwl
    BarredOwl Member Posts: 2,433
    edited July 2015

    Hi Marie:

    I was also surprised that I could not a get clear answer from my insurer at the time. [Insert mini-rant]. I had heard that a typical plan might cover 2-3 mastectomy bras per year and a pair of forms every two years.

    I looked at my insurance coverage document on-line and then called to inquire about what it meant. Supposedly, the co-pay was 10% (after a $300 deductible/per member/payment year) if in network, or 30% if out of network, provided it was the "least expensive piece of equipment" that meets the needs. It said nothing about the number of bras.

    When I called the insurer to ask if the boutique was in network, they said it was not listed. They could not elucidate the number of bras, or enlighten me about how I could possibly know if an item was the least expensive that meets needs. They told me the boutique will know (i.e., the boutique that may or may not be in network!).

    I decided to buy some items on my own, and to save my insurance (whatever it was!) for real pocketed mastectomy bras and good silicone forms. A silicone form can be ~$250 (or more) for a single one. I got a prescription for prosthesis (required), and when I went to the boutique, they told me my insurance provider typically covers three bras and a pair of forms, which I got. I believe that the boutique was considered part of the hospital (in network), and in fact, the insurance covered 100% of the three bras and pair of silicone forms. (That was June 2014, Blue Cross Blue Shield PPO of either MA or IL).

    I was told that the silicone forms could be used for swimming, but I decided I would not subject them to this. Instead, I bought dedicated swim forms myself from MetroMedicalOnline (Amoena Aqua Wave Swimform Style 149 (a pair for $180)).

    Hopefully, others will chime in about their experience with coverage, and how to obtain more definitive information from the insurer in advance, if possible.

    BarredOwl



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  • sewingnut
    sewingnut Member Posts: 1,129
    edited July 2015

    My insurance paid for "cranial prosthesis" which was my wig. They also paid for bras & prosthesis and lymphedema sleeves. All needed RX from my Oncologist. Mine were reimbursed 100% because I had already met my out of pocket catastrophic deductible. Had I not met that they would have reimbursed 80% with a coinsurance of 20% after deductible. I have an Anthem Federal plan.

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  • Marie711
    Marie711 Member Posts: 87
    edited July 2015

    Thank you ladies. I thought all this would be easier! The place in town had exactly ONE bra to choose from in my size! I think I'm going to experiment with sewing a pocket in bras I already own. I went ahead and had them order three bras because they thought the insurance would pay for them. The lady there said insurance companies usually pay what Medicare does and that is 3 bras a quarter. Next time I may drive to a bigger city and hope they have a bigger selection. Has anyone found a lower cost alternative if you don't want to use the expensive form, like when you swim or work out?

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  • sewingnut
    sewingnut Member Posts: 1,129
    edited July 2015

    Marie, I sewed pockets into my old bras until I could find ones that fit. I used one of my husbands white t shirts that had a little give to it. Here is a little tutorial on BCO that I had bookmarked. Be aware, unless you are having a bilateral the prosthetic side using the polystyrene beads will ride up because of lack of weight. I made my own in the beginning using plastic pellets I found in a craft store. https://community.breastcancer.org/forum/82/topic/754464?page=4#idx_97

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  • BlownOffCourse
    BlownOffCourse Member Posts: 37
    edited July 2015

    My insurance will pay for 6 bras per year and a new set of forms every 2 years, subject to deductible and co-insurance (80/20). It was interesting trying to get the info from the young man I talked to. I had to explain what a prosthesis was and spell it for him :).

    You should visit the All Things Bras and Prosthesis thread. They have great people there who can answer almost any question! https://community.breastcancer.org/forum/82/topic/...

    Hope I did the link right!

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  • pajim
    pajim Member Posts: 2,785
    edited July 2015

    I live in Massachusetts which seems to have special requirements. In any case they pay for a form a year, plus three bras up to a certain amount of money. I needed a prescription for the first form, but after that I'm on file.

    I get forms, but buy bras I like. Mastectomy bras never seem to fit. The store will sew pockets for $10 or so. I don't sew very well.

    I've never tried to get them to pay for mastectomy swim suits or anything like that. I use my silicone form in my swimsuit, and go lopsided when I work out.

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  • KickinBootay
    KickinBootay Member Posts: 38
    edited July 2015

    My insurance denied my claim for a "cranium prosthetic" I have Blue shield of California.....

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  • gardengypsy
    gardengypsy Member Posts: 769
    edited April 2017

    My BCBS paid for my breast prosthesis - $525.00

    They also paid for wigs, although I did not get one..

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