DME questions going on Medicare

Type 1 and LADA
1

Hi - On Feb. 1, I go onto Medicare. I currently use the Dexcom G4 and OmniPod. For those who may have recently gone onto Medicare with these devices, can you tell me if I’ll need to go though the approval process for them (or move to the G6) all over again? Any tips or words of wisdom are much appreciated. Also, do you get your supplies directly from Insulet and Dexcom or some 3rd party? - Thanks.

PS - I’ve managed to accumulate enough excess supplies over the years that I have enough to last me into April/May.

2

Medicare covers G5 and G6. If you have supply of G4 sensors, they also work with G5, but you would need transmitter (and receiver or phone app).
But Dexcom is in process of switching users over to G6, and depending on sourcing from Dexcom vs 3rd party DME, your choice may be limited to G6.

I’m not familiar with omnipod MC coverage.

3

If you go through the “Red, White, and Blue” Medicare, then your DexCom supplies will most likely come from Walgreen’s and you almost certainly will have to move to the G6. For the longest time Medicare considered CGMS devices (continuous glucose monitoring systems) to be “investigational”. It has only been since DexCom brought a CGMS device to market that no longer need to be calibrated with daily finger sticks that Medicare has started singing another tune.
So far Walgreen’s is who Medicare has agreed to have the supplies run through. Give them plenty of time, particularly for the initial fill. If it works how it works here, your provider sends the prescription to a Walgreen’s “brick and mortar” store. Then they send it to their “Medicare hub” in Danville, IL. The hub will request chart notes from the doctor, makes sure everything meets Medicare requirements, and then they contact you to arrange how you want to get the supplies. Even though it is going through the pharmacy, it is processed as a “medical benefit” (other words, through Part B) just as prescriptions for glucose tests strips would. The chart note documentation needs to have how many insulin injections a day you are on (or that you are on an insulin pump), that you have been testing your blood sugars a minimum of four times a day for at least the last thirty days and that use of the continuous glucose sensor would be benefit in help you adjust insulin dosing.

If you select a MedAdvantage plan the, most likely it has to be processed by DexCom and sent to a third party supplier. The MedAdvantage plans are eventually going to be handled through Walgreen’s too BUT, at the moment, they are not set up to do so.

Omnipod: Medicare didn’t allow Omnipod until about January 2018/2019. The downside is they allow it only has a prescription benefit. The bad thing about that is that it puts you into the “coverage gap” faster. Supposedly the “coverage gap” is disappearing this year but I don’t think it is quite to the extent that people think.

Basically, after the Medicare prescription drug plan has spent $4,020 (2020’s amount) on covered medications then you go into the coverage gap. While you are in the “coverage gap” you have to pay 25% of the plan’s cost of the brand name medication, the manufacturer “discounts” 70% and the plan pays 5% of the drug cost. (The plan will also pay 75% of the dispensing fee).

You don’t exit the coverage gap until you reach $6,350 out of pocket. Now the good news is that your yearly deductible, coinsurance, and (prescription) copays from January 1st on (or in your case February 1, since that is when your Medicare is starting) all get counted towards that $6,350 so, when you actually do fall into the coverage gap you don’t have the full amount to meet before coverage kicks back in. The other good news is that the 70% “discount” from the manufacturer also counts towards that $6,350.

You do not get out of the coverage gap until your have reach $6,350 (in 2020). Anyway, because the Omnipod is processed through Part D (prescription) instead of Part B (medical), you eat up the $4,020 faster and fall into the “you paying 25% part” faster.

The other thing about Omnipod being processed through Part D (vs. Part B) is that you can’t get your insulin through Part B either. Patients using insulin pumps whose supplies can be process under Part B (Medical) can usually get their insulin through Part B. When insulin can be processed under Part B, it doesn’t contribute to you falling into the coverage gap and, once you are in the coverage gap, you can continue to get the insulin without paying the “donut hole” (coverage gap) prices. (Note: Getting insulin through Part B can be a little more difficult to do when it is a MedAdvantage plan, depending on the plan).

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4

DME supplier may depend on where you live. Some places are competitive bid areas. I live outside Philadelphia and am in one. I get my Freestyle Libre through Edwards Healthcare (under Part B even tho I am T2). I’m in the process of switching to Dexcom & don’t know where they’ll be coming from yet. I also just got my first order of Omnipods (my Part D plan is the AARP/UnitedHealthcare plan) and they did come mail order from a Walgreens in NJ. The Omnipod reps were completely hands on in that process, working with my Endo for approval and even calling in the order to Walgreens with me.

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@MarlboroNick:

First, let me welcome you as a new member of the Gray Tsunami …

Even though you currently have an Omnipod, you will need Medicare approval for coverage of ongoing supplies and that will likely require a very specific set of data and specific things written in the prescription. Omnipod should be able to provide all of those specific details. Similarly, Dexcom will be a good resource, particularly if you are just starting with them, on SPECIFICALLY what you or your doctor need to provide to get Medicare coverage.

And, if I am not mistaken, ongoing Medicare coverage requires that you have appropriate SIGNED chart notes from your endo every 6 months. That may be a change for you …

And, insulin for a pump is a Part B (rather than Part D) benefit under Medicare. That makes it an oddball prescription … and is one that few doctors know how to properly craft to get covered by Medicare and that surprisingly few pharmacies know how to process. While you’d think that everyone on an insulin pump needs insulin … and they do … getting insulin covered under Part B is surprisingly onerous for many. Frequent contributor @Dave44 has the scars to prove how challenging this seemingly simple matter is under Medicare.

Finally, as a G5 Dexcom Medicare user, I still get my sensors and transmitters directly from Dexcom. I’m on the verge of switching to G6 … and maybe my G6 monthly supplies will come from Walgreens. Medicare will cover either, but it is curious that G5 monthly supplies come from Dexcom and (I gather … I won’t know for sure until next month) G6 supplies come from Walgreens.

One other curious thing: my Medicare-covered Tandem pump supplies are shipped as a 90-day supply. For Medicare patients (at least for G5 …) Dexcom is only allowed to send me a 30 day supply. Not only is that odd, but it triples my work to keep me supplied and triples Dexcom’s effort to supply me.

Note: I’m not complaining … between Medicare and my BCBS supplement, I don’t pay a nickel for this stuff. I’m a very happy and lucky old camper!

Best of luck,

John

6

I’d like to thank you all for taking the time to respond to my questions - you provided a lot of good info. Strange that coverage for one may be Part B while the other Part D. I’m retired and opted to get Supplemental coverage through my previous employer. When I used the Medicare tool to select my Part D plan, I tried entering both devices and associated supplies into the tool as prescriptions, but the tool did not recognize either (it did recognize the insulin, though). Thus, I figured both devices and supplies would be covered as DME under Part B.

It looks like there’s a bunch of strict rules/words that need to be followed to qualify for coverage. I never would have guessed that I would need to increase seeing my Dr. to every 6 months. I guess forewarned is forearmed.

7

Actually you will be seeing your doctor every 3 months if you go on the pump. Every 6 months id for patients on MDI (Multiple Daily Injections).

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You will have to do your homework on Omnipod. As others have said it is not considered to be DME by Medicare and is dispensed through Part D. Certain Part D plans do cover it. I tried out Omnipod last summer for a few months. My Cigna Healthspring plan covered it at Tier 3 and it was very expensive, especially since I have no out of pocket cost for my tubed Tandem X2 pump, its supplies, and my insulin.

Because Omnipod is not considered to be DME, you are not eligible for insulin under Part B. Saying that, there are some people who have managed to get that coverage, but I believe it is in error. With a tubed pump which is DME, all of its supplies (including insulin) are considered to be DME. But for Omnipod, it is not DME and therefore anything that goes with it is not DME. Medicare basically considers Omnipod to be a glorified syringe.

So Omnipod under Medicare is hugely expensive compared to a tubed pump. Some people have changed away from it for that reason. Others who can afford the cost have stayed with it. Fortunately I absolutely hated Omnipod and was thrilled to return to my tubed pump after a two-month trial.

Because Omnipod is covered under Part D, I do not believe that you are required to see your prescribing doctor every 3 months as those of us with DME pumps are required. But you would have to check with your supplier. Dexcom definitely requires being seen every 6 months. Here is some info from the Dexcom provider website about the requirements for Medicare patients.

And here are alternative suppliers to Walgreens.

I am currently getting my G6 supplies (as well as my pump supplies) from Solara. They were OK until my current shipment that is 10 days late and has not shipped. I may switch to Walgreens in the future. TBD…

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For pump users you have to have signed chart notes every 90 days (though I’m not sure if it is true with Omnipod because they process it differently than Tslim and Medtronic). Medicare is ANAL about 90 days. Heaven forbid if you need supplies and your last visit was 91 days prior. It looks like Omnipod may be obtained at a pharmacy (at least when it was initially released.) Sensor documentation is every six months.
Medicare is essentially a law so the way things are written don’t often give you much wiggle room until the law is changed (which is a process). Originally, Omnipod wasn’t covered for Medicare patients because of a technicality in wording. (Basically Omnipods aren’t “insulin pumps” {Medicare’s opinion, not mine} because the insulin delivery device is disposable it didn’t meet Medicare’s definition of “durable medical equipment” so couldn’t be processed as such.) A new guideline put out for Part D plans state “medical supplies associated with the injection of insulin,” which aren’t already covered by Part B, are covered by Part D. Thus opening the door for Omnipods to be covered as a prescription benefit.
As I mentioned before, I do not believe that insulin used with Omnipod is covered under Part B like it is with the other insulin pumps. Again, it has to do with language. Medicare covers drugs under Part B that are infused through a DME (durable medical equipment) device. Since Omnipod is not considered durable medical per Medicare, the insulin used with Omnipod is not considered to qualify for Part B. (If there are people out there that have managed to get it to be otherwise, more the power to you but, strictly speaking, that is how it works.).
You mentioned your supplement is through retiree employer benefits, does that include prescription coverage (a lot of time it does). If so, this puts you in a little different situation and, potentially, better place to be. I don’t know your specific circumstances but, in general, many employer benefits plans (for retirees) work a little differently. The downside is it may make it more challenging to get the Omnipod. Medicare can only influence Medicare Part D prescription drug plans. So, if you have an employer plan as supplemental, and it has drug coverage, then the employer plan may not offer Omnipod as a prescription benefit (and they don’t have to because they are not a Medicare drug plan, in general circumstances). It could make things difficult since Medicare won’t process it under Medical and the employer plan may not process it under prescription. The good news is, again depending on how things are, if you have your drug benefits through a retiree benefit then, most likely, you will not have to deal with the donut hole (coverage gap). The other plus is, if it is not considered a part D plan but a plan through the employer retiree benefits then you may be able to use copay cards on prescriptions (in reducing cost). Medicare, Medicaid, VA, and military insurance are not allow to us copay cards. (A story for another time) but employer retiree benefits might be able to. If that is the case for you, you do typically have to tell them that even though you are Medicare age, you do not have Part D benefits. (Or something to that effect).

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Also, for clarification, patients that are new to getting DexCom through Medicare are processed through Walgreen and get the G6. (Though this only applies to traditional Medicare). Patients who have Medicare and have being getting their supplies through a third party vendor or through DexCom have remained with the third party vendor or DexCom for now. The plan is to transition all Medicare patients to Walgreen’s at some point but they are working at getting the process running smoothly before they move everyone. Given that you are transitioning onto Medicare, I’m not entirely sure if they will just continue you as you are or require you to transition to Walgreen’s.

Walgreen’s was supposed to do all Medicare patients, traditional Medicare and MedAdvantage plans, but when it got down to it they weren’t set up to bill MedAdvantage plans for these types of supplies through DME. Rumor has it though, they are working on fixing that.

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Argh! My head hurts! Looks like things are still in a state of flux even though the announcements saying Medicare would cover both the CGM and OmniPod came out year(s) ago. Silly me. I thought it would be a rather straight forward process to transition from my current HSA medical insurance to a Medicare supplemental plan. Boy, was I naive! I appreciate all the news about what’s actually going on behind the scenes by the knowledgeable people on this forum who apparently have suffered though this in the past. Thanks.

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Does anyone know of omnipod dash is handled differently?

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When I tried out Omnipod last summer, my Cigna Healthspring Part D plan covered both the Dash and the older Eros Omnipod. They were both in Tier 3. I chose to go with Eros because I wanted to Loop but I could have gotten Dash.

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OK, I finally got my G6 supplies from Walgreens yesterday after taking almost 6 weeks. My Dr. phoned in the Xmtr/Rcvr/Sensors Rx back on Feb. 14 and I picked up the items on 3/11. This included waiting about 10 days for my Supplemental insurance ID card to arrive as well as a 4-day delay for the Rcvr and Sensors initially being ‘out of stock’ after getting the OK for Medicare coverage. Omni-Pod still in the works.

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Placed my order yesterday for the OmniPods. This took some time to finally get everything resolved including the time/coordination between Insulet, my Dr. office, and my Part D plan which required petitioning my Part D plan to cover these as it was not on their formulary list.

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16

Glad to hear that you got your pods.