Insulin and Medicare coverage

I had a surprise recently, after getting my first prescription for Novolog filled. I had done some reading here and on Medicare’s website (which, immho, contradicts itself as to what it does and does not cover) about insulin coverage, and had gotten some advice from my CDE and my doctor’s office.

I have an insulin pump, have had for years, and I thought Medicare would cover insulin under Part B. Well, surprise, surprise. If you have a Medicare Advantage HMO, Medicare doesn’t cover insulin. Neither my pharmacy nor my insurance company could explain it.

Before I try getting in touch with Medicare, has anyone else had this happen to them, and if so, could you shed any light?

Medicare Advantage plans are Medicare approved but are not actually Medicare. They act in all the expected ways but are actually plans offered by private insurance companies. They often add some coverage, like gym memberships, to the traditional items Medicare covers.

If you want Medicare coverage under Part B for pump insulin, then you’ll need to change your Medicare selection during the next open enrollment to traditional Medicare. Having said that, I have traditional Medicare and I’ve run into difficulty getting any pharmacy to provide the more expensive analog insulins (Apidra, Humalog, ad Novolog) under Part B. Since I have supplementary coverage that will pay for this insulin on an 80/20 split, I gave up fighting and just use that coverage instead of Part B.

The trouble is that Medicare only wants to pay what it considers a “fair price” for the insulin and that’s at a level where the pharmacy either doesn’t make a profit or even loses money. I have read reports on this site, however, where people claim Medicare does pay for their analog insulin under Part B for pump users.

Well, here’s the other thing. Part B covers the test strips I use for my pump system, and my pump supplies, all of which are far more expensive than insulin, which it doesn’t cover. So, it’s not that I don’t have Part B. When my pharmacy called Medicare to clarify, they were told that it’s because my insurance is HMO that they won’t cover it. I’ve had HMO insurance for decades, literally, and have never had anything like this happen. And, of course, none of this was included in any of the information I got when I was selecting insurance.

And, yes, Medicare’s website even says that it doesn’t cover insulin, unless you use a pump.

As @Terry4 indicated, most Medicare Advantage plans include Medicare Part D coverage (prescription drugs). You need to make sure that the Medicare Advantage HMO plan you joined has Part D prescription coverage. If it does then you may simply be finding that Novolog is not on their formulary. As @Terry4 said, insulin is only covered by Medicare for pump use under Part B otherwise it is covered by your Part D coverage in the same way that private insurers cover you.

I’ve been a diabetic for 30 years, and now I’m an old diabetic with other health issues. Prescription coverage is the first thing I look for in health insurance, so, yes, I have Part D coverage. My question is why Medicare would privilege some types of insurance plans over others.

HMO insurance emphasizes preventive care. For a type 1 diabetic, the primary prevention mechanism is taking insulin. I guess that’s what’s surprising me the most.

Medicare only sets the requirements for private insurers who wish to offer Medicare Advantage plans. Medicare doesn’t privilege any insurance and it doesn’t sell or service prescription coverage (Part D), it only sets minimum requirements. You need to dig into what is happening. Either you ended up on a Medicare Advantage plan that doesn’t have Part D coverage or your plan doesn’t cover Novolog, but instead covers some other modern rapid insulin. If the second is the case and you have a good reason to continue with Novolog then your doctor should be able to write a letter of medical necessity and obtain coverage.

I suggest that you join the insulin Pumpers forum and ask your question there. It is kind of a weird forum in that it runs in an email format. You must join the site and be sure to select the option to read the posts online. Otherwise your inbox will get inundated. The reason I suggest Insulin Pumpers is that there are many people there with Medicare knowledge and experience. Also there are some members with Advantage plans and others on traditional Medicare with a supplemental.

http://www.insulin-pumpers.org

I just started Medicare in April and despite doing lots of homework, I was never quite sure whether I would be able to get my insulin covered under Part B with an advantage plan or not. And then I think that Advantage HMO’s are a different type of plan than I was looking at. I chose to go with traditional Medicare and a supplement for many reasons, one being Part B insulin.

I get my Part B insulin through Walgreens and I have heard more than once that they are the best source for Part B insulin. When I filled my first prescription in April I instructed the Walgreens tech that it should go through Part B. Of course it didn’t and I went to talk with the pharmacist. The tech had no clue how to fix it, but the pharmacist was familiar with Part B. She said that she would take care of it. I got a call later that afternoon from the central Walgreens Medicare department. I had to provide information on my pump brand, serial number, when it was purchased, etc. When I refilled the prescription, I reminded the tech about Part B and it went through with no problems. Medicare pays Eighty percent and my supplemental pays the remaining twenty percent.

Thanks for that suggestion, Laddie. I’ll be sure to check out the pumpers forum. I’m new to Medicare also, and I did homework also. Of course, none of the issues I’m having now were included for any of the plans that were available to me, and it didn’t occur to me to ask. I’ll take this as a learning experience, and very likely change my coverage at the end of my plan year. As I said in one of my comments, I’ve had HMO insurance for years. I carried the insurance for my family. When my husband was treated for cancer, it covered surgeries, radiation, hospice care at the end. So, when I saw that HMOs were available to me, I thought nothing of continuing with the same kind of coverage I had had for so long. I guess this is just part of the Medicare learning curve.

Laddie, Part B also covers test strips

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Yes, I was able to get test strips through Part B, just not insulin. It took two tries, as my doctor submitted the order for test strips as a prescription, and the first attempt went through Part D, which was declined. We finally got it worked out.

Thank you for all of your helpful info. My husband is Type 1, on a pump and just started Medicare. He finally got Walgreens to fill his insulin prescription but they will only do one vial at a time, even though the prescription was for three. Do you have this same problem?

My prescription for insulin is one vial per month, but the prescription is written for a certain number of units per day. When I pick up my insulin from Walgreens, I get 3 vials for a 90-day supply.

Thanks. His was written for units per day as well but they would only give him one vial for zero payment. If he wanted three, they were going to charge him $115. So strange. Luckily we live close to Walgreens. Next he will try to get test strips - he uses 8-10 per day. Thanks again!

Is there a medicare advantage PPO that you can get? I had a PPO Advantage coverage Just last year and they covered Nololog. I have a pump also. My part B covered it.

I have been going around recently with my pharmacy and Medicare and my Part D plan about who covers what. I use the Dexcom CGM, covered under B and Durable Equipment so anything Medicare doesn’t cover is covered by my Gap insurance. I use the Omnipod insulin pump, it is NOT covered under Part B because it is tube-less!! It is now covered under Part D, my part D plan covers them at 50% until you fall in the donut hole which came very quickly. And insulin is only covered by part B if you have a pump covered by part B, aka a tubed pump. I am in the process of deciding if I need to go to a tubed pump or do without a pump or if another plan is more generous with the tier level for the pump and insulin. I am not just a little upset that the pumps covered by part B are so narrowly defined. I would not have any out of pocket costs if both my insulin and the pumps were covered under part B as it is my out of pocket is going to be in the thousands. I am new to Type 1 (2 years) and Medicare (1 year).

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Judy, I don’t think it’s so much that the Omnipod is tubeless, as it is that the pods, which house half of the necessary technology, are disposable, and therefore not durable, which they must be to fit the Part B definitions. That’s how my CDE explained it to me, and the light bulb came on, and it made sense. I didn’t find any of this out until two weeks before I aged into Medicare, and had to switch over to a MiniMed. I’m still fiddling with tubes, which I don’t love, but the out-of-pocket costs for the pods are just out of my range.

I used the Omnipod for years, and I think their use of the technology is innovative. I loved being tubeless and wireless. In my case, however, by the time I had to stop using them, I was beginning to have skin issues; not a rash, no skin irritation from contact with the adhesive, but blistering around the edges of the pod site. To be honest, though I’ve not been able to confirm this anywhere, I think it was friction burns, from the weight of the pod pulling on the edges of the adhesive pad. My skin has gotten thinner as I’ve aged, and I’ve finally gotten a Hashimoto’s thyroiditis diagnosis, though I’ve had symptoms for years. So, changing worked out for me. The tubing is still a PITA, but no blisters. :wink:

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