CVS will enforce 3x/day Medicare test strip limit


#1

I’ve been getting my Medicare Part B insulin and test strips from CVS. Yesterday I receive these two texts about a change in CVS policy regarding test strip quantities.

58%20PM

13%20PM

In the past, I have been a heavy user of test strips, up to an average of 15x/day. More recently, I’ve cut back to five strips per day and depended more on my continuous glucose monitor readings.

This is the kind of fight I’ve easily joined in the past but now I wonder whether it’s worth it or not. I think it is ignorant, unfair, and unhealthy for Medicare and CVS to engage in this policy trend. Medicare policy, by the way, permits the doctor to over-ride this quantity limit as a medical necessity. CVS has taken this one step further than Medicare.

So, they’re willing to give me 3x/day without a fight. As I think about the time spent on hold to talk to some nameless, faceless bureaucrat would be best avoided. I don’t deal with it well, even though I attempt to remain calm.

What do you think? Is this a fight worth fighting?


#2

I know nothing about CVS, but Medicare is really shooting themselves in the foot, if they make it harder for some folks with diabetes to monitor their own glucose levels, Medicare is going to eventually have to pay for hospital visits for diabetic complications. That will cost them so much more in the long run. Seems very shortsighted to me.

Many decades ago I fought Uniform Insurance about this, and they ended up taking off the limits on test strips. The insurance company was much, much smaller then, and my voice could be heard.

I do think it is an issue worth fighting, but only you can make the decision on whether you want to put forth the effort since it won’t effect you directly. As for CVS, I would buy strips somewhere else if possible.


#3

Thanks for the reply, @Marilyn6. I decided to pick up the phone and inquire with my Rx plan, CVS Caremark. To my surprise, I found out that my brand of test strips, Accu-Chek, is the preferred brand at my Rx plan and I can get whatever quantity the doctor prescribes with a $0 copay. So, my problem is solved.

Unfortunately, some of my fellow persons with diabetes will be impacted by this unfair policy change.


#4

I didn’t mention this in my reply to you on Facebook, but you can get 3 vials a month from Dexcom for 150 strips and that is 5 strips per day. I am on Basic Medicare with a supplement. If you’re on an Advantage plan, your options might be different.


#5

I’m still working and getting a nice health insurance benefit from my job, but 65 is only five years away for me. I’m scared to death because of all these Medicare horror stories I keep hearing. I like to test 8 times a day. I’m still doing everything the old fashioned way — MDI and finger sticks. (Hey, it works for me. I get good numbers).

Again, I’m scared to death that I won’t be able to get what I need to stay alive and stay well.

Medicare = curl up & die??


#6

Are there specific brands to choose for BG strips?


#7

I’m still using the G4 so I’m thinking the strip supply you’re talking about is bundled with G5 supplies. Am I getting that right? I use standard Medicare plus a plan G supplement. I plan to switch to the G6 when Medicare approves access.


#8

Medicare or any other insurer could care less about cost in the long run - they will just raise rates - they are all in the misery business - the more misery for anyone but them is their lifeblood - simple fact


#9

I switched to Medicare a few years ago. I also maintain a supplement plan. Before that I worked for a large company and enjoyed good benefits like you describe. Medicare is a good deal; there’s nothing to fear.


#10

I have not seen this but the number of appeal letters that I see CVS losing on my account does not surprise me. If worse comes to worse, I will use Medicare and my supplementary employer plan to get the test strips I need. I use between 8 and 10 per day and I am always happy to supply the documentation but so far they have not asked for the documentation.


#11

If you’re getting the Medicare bundle from Dexcom, you are provided Contour Next strips. Since that is a brand that I am happy with, I don’t think about the hassle of trying to get a different brand. Medicare people who get their Dexcom supplies from a supplier are often supplied with different brands of strips.


#12

Yes, I am talking about the Medicare Dexcom bundle. I have seen on Facebook that others (not just Medicare) got the same CVS message and it has been resolved by their doctors filing new calendar year letters of medical necessity.


#13

Are you sure you doctor’s office hasn’t been supplying that info all along?


#14

They have not, I got my notice from CVS today.


#15

I’ve never supplied any documentation, for anything, to any pharmacy, ever, EXCEPT prescriptions. I’m still not understanding why you are the one to provide documentation beyond prescriptions.


#16

One way around the 3 strip per day rule is to supply all your readings for a month once every six months. The pharmacy can submit this to medicare as proof that you are using the higher monthly total.

Some mail order companies do this it is my understanding that CVS will not.

Since CVS has decided not too, it is unlikely many mail order companies will do so.

To answer the question, it is a way to go around the medicare rule of three per day if the supplier will do it on your behalf.


#17

the rule isn’t “3 per day” as Dexcom automatically sends all Medicare patients on a G5, 150 strips per month. that is 5 per day, and that is while using a CGM.


#18

Medicare allows three times a day if you are on insulin and one time a day if you are not on insulin. (Four times a day if you are on an insulin pump which may not be stated in the “test strip rules” but Medicare WILL NOT pay for an insulin pump and/or supplies unless you are testing exactly four times a day). Medicare allows for patient’s to exceed that if it is documented in the patient’s chart file. What many patients (and providers) don’t realize is Medicare audits the BAHOOEY out of pharmacies. In 2011, Medicare did some sort of study and discovered it had allowed 6 million dollars in claims to be paid out “inappropriately”. There were three types of errors: 1) They paid for test strips when patient through the retail pharmacy when the patient was in the hospital. 2) They paid for test strips through retail pharmacy when patient was in a skilled nursing facility. 3) They paid for test strips for people who “without documented diagnosis code for diabetes.”

(I had to laugh at #3 because one of the top five reasons given (instead of diabetes) with the last one was: “Chronic long term use of insulin.” I can’t think of many reasons that a person would be using insulin without having a diagnoses of diabetes and anyway, anyone using insulin, regardless of the diagnosis, should be allow to test their blood sugars.)

So now Medicare audits the pharmacies to death. (They even audit the pharmacy twice on the same patient in a 30 day period).

Medicare lays out it’s requirements for the “documentation” and, on paper, it doesn’t look TOO bad and, in the beginning it wasn’t.
This auditing process originally started to make sure that the government wasn’t paying out claims where they shouldn’t but it has taken on a life of its own.

Knowing the documentation required, I would say that the vast majority of the providers don’t submit documentation that is up to the Medicare test strip police’s exacting standards. Don’t get me wrong, I think that most provider’s documentation is more than adequate to answer the question of whether the test strips are medically necessary it just that as time as passed and more and more providers are meeting that documentation requirement, the auditors are being hard pressed to find things “wrong” and so are nit-picking over the slightest thing.
Here are the requirements for the prescription:
There must be a written order for all testing supplies. The written order must contain the
following elements:
 That they have diabetes
 What kind of blood glucose monitor they need and why they need it (that is, if they
need a special monitor because of vision problems, their doctor must explain that.)
 Whether they use insulin
 How often they should test their blood glucose

That sounds simple but here’s the “extras” that are also “required”:

  1. You cannot use a range for test supplies (such as 4-5 times a day). It must be an exact number.

  2. It must be a “wet” signature so if it is sent electronically and the pharmacy doesn’t receive with a copy of the “actual signature” but an electronic version then it must be done again with a “wet signature.” (To my knowledge this is not the case with anything else.)

  3. You must write the diagnosis code (ICD10) for the diabetes not the words “Type 1” or “Type 2” but you cannot use the diagnosis code for insulin (you have to physically write “on insulin or not on insulin”) (This one is a 50/50, depends on the auditor).

  4. If you have to fill out a prescription “form” there can be ABSOLUTELY no errors, cross offs, hesitations, “write over”, white out, etc. Doesn’t matter if the provider signs the errors and dates them. You do any of that and you have to start over. (It didn’t used to be this way but it kept getting stricter and stricter and stricter.

If the testing exceeds Medicare’s allotment then “officially” what is needed is:

  1. Basic coverage criteria for all home glucose monitors and related accessories and supplies are met; and, (That they are diabetic and are trained to use the glucose meter)
  2. Within the six (6) months prior to ordering quantities of strips and lancets that exceed the utilization guidelines, the treating practitioner has had an in-person visit with the beneficiary to evaluate their diabetes control and their need for the specific quantity of supplies that exceeds the usual utilization amounts described above; and,
  3. Every six (6) months, for continued dispensing of quantities of testing supplies that exceed the usual utilization amounts, the treating practitioner must verify adherence to the high utilization testing regimen.
    TYPES of things that may be in the documentation:
    Names, dosages, and timing of administration of medications used to treat the
    diabetes;
    o Frequency and severity of symptoms related to hyperglycemia and/or
    hypoglycemia;
    o Review of beneficiary-maintained log of glucose testing values;
    o Changes in the patient’s treatment regimen as a result of glucose testing results
    review;
    o Dosage adjustments that the patient should make on their own based on selftesting results;
    o Laboratory tests indicating level of glycemic control (e.g., hemoglobin A1C);
    o Other therapeutic interventions and results.
    ALTHOUGH, “Not every patient medical record will contain all of these elements; however, there must be enough information in the patient’s medical record to support the medical necessity for the quantity of item(s) ordered and dispensed.”
    REALITY:
  4. Listed on the chart note under medications must be the test strips and lancets with
    all the information like it was a prescription.
  5. It should also be in the discussion section.
  6. Be sure to use the “most present tense” language such as “is currently testing” not just “is.”
  7. Thirty days of glucose logs. (It says you have to have documentation that you reviewed the logs…Uh, no. Physical logs are a must.
  8. You must state justification in EVERY SINGLE NOTE even if it hasn’t changed. Such as “Patient has been testing and is currently continuing to test their blood sugars six times a day. Patient doses their insulin on a sliding scale and checks their blood sugars before each meal and then two hours after each meal to monitor insulin dosing.”

As a patient, if your prescription says you are testing four times a day. Then you’d better be testing exactly FOUR times a day. Not three. Not five. Heaven forbid, one day you test more frequently or one day you test less frequently. Oh, and there is no such things as “dud” strips (Being sarcastic). And NEVER, NEVER, NEVER, EVER share your test strips with your spouse (even if the are also diabetic and have their own prescription for test strips) because that is a MASSIVE mess. (Again, being

CVS is probably tired of getting their money taken back by Medicare when technically the documentation most likely fits the WRITTEN requirements.

The whole thing is a Catch-22. CVS is not the patient’s medical doctor. It is not up to them to determine what is medically necessary.

That being said, they are a business, and if they are losing significant amounts of money because of Medicare auditors’ overzealous enforcement, then I get that they can no longer deal with this.

If you want to complain, you need to be complaining to Medicare for making it so difficult that pharmacies don’t what to support Medicare patients. Personally, I’d love to do a study of how much money Medicare has taken back inappropriately when documentation fits the requirements that as they are written. I can bet it is a lot.


#19

LOL at “chronic use of insulin”. haha. Shame on us! We are druggies. /s


#20

I had an HMO plan for one year which for me had terrible service. Urgent care clinics were a joke. the doctors would practically run in one door and out another in the examination room. Literally, they came in one door and exited out another. Time spent with patient was about 5 minutes. Diagnosis was inadequate. Minor surgery was literally a “pain” because the hospital had ineffective local anesthetic, requiring repeated injections to offer a modicum of pain relief during excisions.
The less they spent on healthcare the happier the HMO. No matter that patients received inadequate care. You could not pay me any amount of money to use a traditional HMO. Medicare is similar but not identical because with Medicare I can see any doctor I like and go to any hospital I want. HMO’s require one to use it’s doctors and facilities. Taking away a doctor/patient decisions is often done by any type of insurance due to their coverage rules. It isn’t just Medicare or HMO’s that get in between the doc and the patient.