My pharmacy has just labeled me an “over-utilizer” because I test about 8 times per day and use Contour Next test strips with my pump and sensor. The Medicare limit is 3 test strips per day unless the “excess” testing is justified with every refill.
Why does Medicare not understand Type 1??? Just to get my pump I had to prove I would test at least 6 times per day. This is unbelievable. I told the pharmacy rep that the label “over-utilizer” was offensive. My endo is great, but there is no reason that he should have to spend his time (or pay someone else) to respond to this nonsense.
Here is the email that I just got from the mail order pharmacy:
Medicare changed their guidelines and the amount of testing strips they would pay for as of July 1st 2016. Medicare decided to pay for 300 testing strips every 90 days if you are insulin dependent and 100 testing strips if you are NON insulin dependent. Medicare requires additional documentation in order to pay for more than the maximum amount of testing strips they are paying for.
Below is the information on what Medicare’s new guidelines are and what they are now requiring in order for you to test your blood sugar more than X times per day.
Medicare wants the following documentation for every refill:
Your office visit notes are the most important******* Please read the information carefully and ensure that your doctor adds the sentence that Medicare is looking for.
#1. Medicare needs the last 2 doctor visit notes (must be within the last 6 months) AND THEY MUST STATE under the PLAN or ASSESMENT section; the specific amount of times you need to test your blood sugar, the reason why, and for how long. IF THE DOCTOR VISIT NOTES DO NOT CONTAIN THAT INFORMATION YOU NEED TO HAVE THAT UPDATED ON YOUR NEXT APPOINTMENT.
An example sentence would be: +++++++ patient needs to test his blood sugar ___times per day due to uncontrolled blood sugars. needs to continue testing at ____ per day for the next 3 months ++++
#2. Medicare needs to see A 30 day consecutive testing log signed and dated by YOU AND your physician on the last page. (IT MUST BE A testing log from within the last 3 months).
#3. Lastly Medicare also needs to see your testing log signed and dated by your physician and they need to see a copy of your A1c lab report.
Yesterday I got my 1300 strips which according to Medicare can be refilled in 86 days. They won’t give me 1400 for 90 days. It’s all because of my testing frequency and the fact that 100 count boxes of strips don’t divide into 90 days evenly
I offered to reduce the amount down to 900 strips or less for 90 days but the pharmacy people and my doctor said no don’t do that because once you drop down it’s a big deal to get it changed again in the future. Crazy rules
they do this for insulin pump supplies. they want you to see your dr every 3 months and needs drs notes from that visit to get your insulin pump supplies. with my cgm stuff i dont need that…im not sure about the test strips as i still have some from my previous refill. it will be interesting to see what they say.
Thanks for the response, but I still feel that Medicare thinks that all people with diabetes still produce their own insulin. The implication is that in order for T1s to manage BGs, we are gaming the system. Unless my endo continues to collect data every 3 months to show that I am still a T1 and need to test 8 times per day, I will be thrown off the proverbial cliff with the Medicare testing limit of 3x/day. If a patient can document once that the c-peptide test shows that there is insufficient insulin production, Medicare should not need to harass medical professionals or patients every 3 months to produce more of the same data. No matter how many reports are submitted to Medicare the T1 on a pump and CGM (“over-utilizer”) still needs to test at a minimum 6 times per day just to calculate insulin dosing. The “excess” testing (8x/day) allows the patient to confirm or adjust for high or low readings. Why is this so hard for Medicare to comprehend??
i wished medicare would understand too. but this is how they want to do things. i dont think they understand how diabetes works. they should. you are right that nothing will change ever on it. i cant remember the reason now why medicare wants you to do this but its what they told me, every three months. i told my endo about it and he was like ok never had an issue before. i also told him i know its hard to get an appt with him for that time frame and he knows its true. Once i run out of the supplies and need another order i will call the company i deal with and see where the info needs to be sent to so i can make sure i can get my next supplies.
I am on Medicare in Utah. I had been using Kmart and they closed. I switched to Walgreens. My CDE filled out their form and I get 400 strips for 90 days. I test 4 times a day and have 40 extra strips to use when needed. My A1c ranges from 6 to 6.5, I am on MDIs. My CDE filled out the form in July 2016 and I have not filled anything out since then. I had done some logs when I was using Kmart, 3 or 4, not every month.
I just had a phone conversation with the person at my small pharmacy who handles Medicare and other insurance claims. I phoned her because I noticed that on the quarterly copy of my claims for Part B Medicare Insurance the pharmacy had put in a claim of $447.84 for 5 boxes of strips (50 strips to a box), and Medicare had paid only $32.61 TOTAL. I thought it was an error. She told me that this is what they started paying 2 years ago. And to even qualify to purchase the strips to sell to their customers, the pharmacy had to pay $10,000 for special accreditation. They paid and got accredited because they wanted their local customers to have access to supplies and drugs they needed at reasonable prices. The pharmacy makes $1 on each box of strips they sell. I am billed nothing. If I were to wish to buy strips from a CVS, Walgreens or Walmart pharmacy, of which there is only the Walmart here, paying out of pocket, the 50 strip single box would cost me almost $80 anywhere else. She says that they charge their customers $1 over their cost if they are paying cash. She feels that this situation is a concerted effort to put the small pharmacies out of business. I think she is right.
I tacked this tidbit to the wrong post. Was not referring to the Contour Next but to the One Touch strips that go with the tester/remote from my Animas Ping pump. These strips are also used with the other One Touch testers independent of the remote. But the shenanigans probably hold true for a lot of pharmaceuticals as the small local pharmacies are being squeezed out.
