Hello…I have been reading the forum for about a year, but have never written
I have been insulin dependent for 35 years. I am male-aged 83 on traditional Medicare
I have used 2-3 Medtronic pumps and had had my Tandem for 13 months Last payment to CCS for the hardware ( I hope).
I stgarted on Dexcom CGM about 6-8 months ago… first on the G5… and after 90 days switched to G6.
First question is about the Dexcom.
I received my supplies directly from Sexcom until the switched me to a supplier 2-3 months ago. From Dexcom, I received my supplies … and was not billed anything.
With CCS I apparently am being charged the 20% that Medicare does not pay. First shipment of 3 sensors I was charged $ 45+. Nobody said anything, and I wondered if Dexcom did not charge because of Medicare problems.
My second CCS shipment included a new transmitter… and I have not received a bill yet… so I don’t know the cost.
I thought perhaps the Dexcom billing was because it was processed under DME ?
Is this what happened when others were switched from Dexcom to a private supplier ?
Second question: For many years I got my insulin through Walgreens and it was billed through my regular insurance under my Rx fee schedule.( several hundred dollars)
A few years ago, the pharmacist switched me to Medicare under DME and I never paid a cent… just the normal pain from dealing with the Medicare paperwork.
This week I received a bill from Walgreen HQ for my Jan 2020 shipment of insulin and since I get shipments every 90 days… I expect more invoices.
The first invoice was for $ 70-80 so it was probably for the 20 % copay… since I get 6 vials of Humalog every 3 months.
I have looked online at my Medicare claims, and they always show the inflated charges people bill Medicare… and what Medicare allows… and Medicare sends the claims to my private insurance… but it never pays anything, since it is not a Supplemental policy, but my insurance from my retirement.
That insurance paid for my first pump… pre-Medicare…and supplies… but since Medicare started coverage at age 65… private insurnce pays nothing for pumps or pump supplies.
I guess I thought since I paid nothing for insulin since they started billing it through Medicare DME I was home free.
When I started the Tandem pump… the inservice rep/RN said I must have had a pharmacist that knew how the system worked to get the insulin free.
So… why I am writing is : I wonder if I am paying about the same as the other patients on traditional Medicare for Humalog and also for the Dexcom.
I am a 72 year old Type 1 diabetic for 32yrs. I have Medicare and a AARP supplemental Plan F that I pay $200 a month.
I am on a Medtronics pump and Dexcom G6. I get my insulin from Walgreens. My pump supplies and sensors I get through Edgepark.
I have no copays since Medicare pays 80% and AARP pays 20%
Look closer at your second insurance coverage. There are several questions you may want to dig out the answers for as they apply to you.
If the insurance is something you have carried since retirement, discuss your second policy’s coverage with your former employer’s insurance specialist. (My ‘secondary’ retirement policy covers Medicare’s 20% & deductibles)
There has been some waffling about Dexcom being a a) stand alone DME, b) pump expendable if it is integrated with your pump, or c) pharmacy item. Again, find out how it is being billed.
Does your employer have mail order pharmacy coverage? Can you use it as a retiree?
If this far thru my ideas, Walgreens is still the place for insulin, Dexcom advertises Walgreens offers Dexcom G6. Discuss the options with the pharmacist there. The pharmacist may pass you off to a Walgreens Specialty Pharmacy (WSP) if there is one in your market. Supposedly, the WSPs are better trained to play Medicare’s games.
By this point, you may need to get out a spreadsheet (computer or pen & paper) type of grid to analyze all of the data amassed chasing this out and acquiring the cost to benefit ratios.
If learning all of this does not allow you to optimize your out of pocket expenses, look at what @edoshea shared about the AARP plan.
Now, to answer your question. I believe you are in a correct position in terms of out of pocket cost and they could be better. I think you will find you will be able to get all of you supplies (pump expendables, CGM sensors & transmitters) and your insulin at almost no cost.
Walgreens is my usual pharmacy and I take a lot of medicine so I’m a frequent customer. But I have to get all my diabetic supplies from other drugstores. Years ago I tried getting my test strips at Walgreens but I had to prepay for them and then they filed the insurance paperwork and several months later I got a check to reimburse me for part of my expense.
.
I have been on the Dexcom since it came out and have needed to use mail order vendors since I went on Medicare.For many years Medicare covered my insulin fully so there was no cost to me. I had to who go to Walmart to get my medicine because Walgreens was not able or willing to do the paperwork to have Medicare cover it. None of the other drugstores in town were willing to do it either. So it was really no surprise when I learned that Walgreens was carrying Dexcom but they will not provide them for me because of my insurance which is Medicare as my primary and a secondary policy that is coordinated with Medicare.
Coverage for diabetic supplies often changes especially with Medicare. Various vendors differ widely in their ability and willingness to do the necessary paperwork for you to obtain the maximum benefits your insurance can provide. Mistakes are very frequent and very common and it is often very difficult for us older people to figure out how much we should actually pay. Usually the best resource is a representative of your various insurance companies but often they will make a mistake in processing a claim too or the vendor makes a mistake in filing the claim.
Since I went on Medicare a couple of decades ago I often joke that getting my diabetic supplies is almost a full-time job since it requires a lot of contact with various vendors to get the necessary supplies and insurance companies to get it paid for.
I really hate dealing with insurance. I’m not looking forward to Medicare for that reason that’s just 9 years off as of tomorrow I’m going to be 55. That is also 34 years since diagnosis.
I have Kaiser Permanente for now and although it is more expensive than average, the insurance issues are very minimal
My co pays are clear and I get a bill once a quarter.
I order direct to dexcom and tandem for my pump and sensors.
I go to the pharmacy for insulin.
I don’t understand why a program like Medicare tends to treat people differently, some have it easy, for some it’s a full time job managing it.
My parents just went on Medicare this year and are frustrated.
It’s is so complicated, if I can get Kaiser to keep me on as a Medicare patient I will do that however they only allow a small number of people in that path.
