My brother is on Medicare and he has Humana’s Advantage Plan. My brother has always gotten his insulin through the Pharmacy co-pay. He’s been using an insulin pump for 3 years and uses Humalog. Humana is now billing his Humalog as Durable Medical Equipment, which means his co-pay is now 20%. The disparity in price is substantial. Humana did this without any advance notice. I am appealing this with Humana. My brother is on disability and this will be a hardship. Has anyone heard of other insurance companies billing insulin as Durable Medical Equipment? One of my points for appeal will be that Humana should have told my brother before he signed up for this plan last fall.
When a person uses Medicare it is customary to have insulin billed as DME, if it is used in a pump. It is a Medicare wide standard. However, it may be possible to opt out of this provision depending on the pharmacy and the PBM. I suggest calling Humana and asking the question if this is required. In some plans it is not. However as I say most Medicare insulin is billed as DME if used in a pump.
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If you use a pump, insulin is covered under Part B. Alert the pharmacy to that or you’ll be billed too much.
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Unfortunately, any insurance at this time may change coverages, on medicines without notice; even those people on Disability or Medicare are at risk.
A mistake must have been made; insulin is NOT durable medical equipment.
It may require his Dr. to back him up with letter explaining and emphasizing that Humalog is the insulin that helps your brother maintains his blood sugar best.
If you are on traditional Medicare and on a pump the insulin is considered a DME. Medicare pays 80% and your supplement will pay the 20% if you have a supplement plan. Advantage plans are another case.
@Dezygnher This is a hard concept to wrap one’s head about, but it is true. I’ve read a lot of posts from many on Medicare explaining to others how to go about getting their insulin covered properly.
Wowzer! No, I have never heard of that. They are fixing the books. What a bunch of gangsters! You should not play nicely with this. You gotta push back and be a gangster when your dealing with this sorta behavior.
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Here’s one of the links I have regarding DME and insulin
DME (part B) covers the equipment and SUPPLIES used with it. A pump alone without insulin is not medically necessary.
As mentioned, some plans may allow coverage choice of B or D. Advantage plans may have their own rules.