Insulin and Medicare

Does Medicare cover Humalog?

Probably a dumb question. But asking it.

Medicare does cover insulin. If used in insulin pump, it is covered under Part B, DME “supply”.

If no pump, then covered as prescription, Part D, and may vary based on what plan you have. They may have novolog instead of humalog as preferred brand.

So depending on your use, and plan, check with provider for brand.

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Should the prescription by the doctor make that clear in some fashion. We are still being charged through our insurance company mail order process.

I guess I am confused. Thankyou.

Sally, I got the same treatment. They (unitedhealthcare) said it wasn’t covered so what does one do?

I am not on medicare, but my endo writes RX for insulin and indicates “use xx units/day, as needed, in insulin pump”. Then I fill at pharmacy, and they determine number of vials based on that.

I think others have posted different experiences with how capable a pharmacist is at knowing how to file as medicare part B or D. Hopefully others will post.

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That is helpful. Ty.

Correction… RX says use UP TO xx units/day.

This includes the amount actually dosed and amount for filling infusion tubing and thrown out.

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I just enrolled in Original Medicare Part B with AARP UHC Supplemental Plan F effective this month. Insulin for insulin pump should be covered under Medicare Part B with deductible and 20% copay to be paid for by the Supplemental Plan F.

Ralph (Kroger) pharmacy informed me that Medicare Part B has approved 3 vials of Novolog Insulin for the cost of $255. Of which, 80% is paid for by Medicare and the remaining 20% ($51) is not paid for yet. Ralph said that is my co-pay. I think that something is wrong. I contacted AARP and they has no record of insulin (Part B) claim been submitted. I suggest Ralph pharmacist to check with their coordinator to find out whether the invoice has been submitted to AARP for payment yet. But, I realize that I have not picked up the insulin yet. I am confused about how to get it work.

Does anyone know how does the Medicare Part B and Supplemental Plan work together for Part B insulin supply? What can I do to expedite?

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It would seem that you have to keep after Ralph. See suggestions above that discuss what doctor should write for perscription for insulin for insulin pump. Does pharmacist understand that the insulin is for Insulin pump?

It’s 80/20 - Medicare pays 80 and you or your supplemental insurance pay the 20

You would think this is how it works but it may not always go that smoothly.

If you are on a pump your doctor needs to fill out

To get insulin under part b

and it must be faxed to medicare

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Well now this is helpful. Thankyou.

Now to get the doctor to do it.

Just looked at this. Looks complicated.

When you get it done make sure to keep a copy as sometimes they decide they want a new one - keep one on file at the pharmacy

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So two ways of working this. If you want the insulin charged as part B and you wear a pump, then have the script sent to your local pharmacy and tell them at the counter. They will want the brand and serial number of your pump and in one case they wanted the name of my doctor.

If you want it charged as insulin under part D (prescription benefit) send it to the local pharmacy or your mail order and it will be paid as normal.

Using medicare the pharmacist is your friend.

I was thinking and talking to my husband about this.

We have been getting prescriptions they mail order.

May change back to pharmacy close by as they are more hands on.

Thankyou

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I’ve been on Traditional Medicare with a supplement (MediGap) G plan for 5-years.

I get all my regular RXs via mail-order (have been using CVS/Silverscript now for two years). I get one-off RXs (say a pain med following a surgery or some-such) at my local CVS (part of the Silverscript plan).

I get my insulin at my local Walgreen’s RX as they know how to process the CMS/Medicare paperwork for coverage of the insulin under Medicare Part B (DME). My local CVS RXs will not process as they don’t want to deal with the Medicare paperwork. Not all CVS are that way. Varies by location.

If you are using a “tubed” insulin pump your pump supplies including insulin are covered under Medicare Part B (DME). That assumes your Medicare plan is a “traditional” plan and NOT Medicare Advantage. The MA plans are their own animal and vary widely by state, etc…

Your Endo has to write the insulin RX very specifically to note use in a pump and some other verbiage that CMS/Medicare wants to see. You will likely have to show the RX some data points from your pump as they also have to fill out the paperwork required by CMS/Medicare.

The RX sends the bill (electronically) to CMS/Medicare and they pay the agreed upon price at 80% and CMS/Medicare sends the balance of the bill to your Supplemental/MediGap provider and they will then pay the remaining 20%.

I have a Plan G and an annual deductible of approximately $185. Once I pay that I have not OOP costs for remainder of year for doctors and insulin.

CMS/Medicare has no say-so on how much insulin I get nor what brand of insulin I get. That is under the control of my Endo.

Remember this is under Part B (DME) … this is not under a prescription at a Part D (RX) coverage plan. There are restrictions on which type of insulin the insurance may or may not cover. That restriction does not exist under Part B (DME).

You have no co-pays or OOP when you get your insulin this way.

Note that I said “tubed” pumps. An Omnipod is NOT a tubed pump and is covered under Medicare Part D (RX) plans, but not all insurance companies have it in their formulary and is bloody expensive regardless even if it is in their formulary. You also have to get insulin under Part D (RX) if you use an Omnipod as well.

A lot to chew on, but it works well once you have a dance or two with your Endo and local pharmacy. The challenge I have every 3-months for my quarterly insulin order refill is that sometimes the pharmacist assistant is new or hits the wrong button and they charge it through Part D (RX). I’ll often have to visit with them to ensure they remember to process it under Part B (DME).

Now that Walgreens has the contract with Dexcom provide CGMs via Medicare they will all be learning how to process such paperwork so it will get better.

I get 7 vials of Novolog (I used to get Apidra) every 3 months. Retail cost is about $2400 and I pay $0.00. I’ve been testing Fiasp and really like it and may have my Endo write a new RX for Fiasp after my next visit with her.

Best of luck.

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Also check your plans formulary, things change every year. Excellent information given.Nancy 50

Nolan.

So wonderful of you to take the time to write all this info down.

Is a Medtronic 670G a “tubed” device.

So it would be covered by Part B Medicare, perhaps?

We are paying so much for our additional insurance.

We would jump on Plan G right away BUT I have Rheumatoid Arthritis and Medicare does not cover Enbrel which is very expensive and is working for me.

So we are waiting for more info to make final decision. It’s an anxious time.

Please explain difference between regular Medicare and Medicare Advantage.

Isn’t Medicare A and B regular? Ty

After making several phone calls to all relevant parties in the past 20 days, Ralph pharmacy finally notify me to pick up Novolog Insulin under Medicare Part B. The $185 deductible and 20% copay will be covered by Supplemental Plan F. I would like to share the following information with those who plan to or just enrolled into Original Medicare Parts B and D:

  1. Enroll into Medicate Part B and Supplemental Plan G (or F) about one month before the effective date. Need a licensed insurance agent for paper work.
  2. Open an account in mymedicare.gov on the effective date.
  3. Visit your Endo’s office as soon as possible after the effective date and have your Endo send e-prescriptions to your pharmacy and Medicare authority.
  4. Monitor your account in mymedicare.gov to ensure your Medicare insurance plans information are up-to-date. My old commercial PPO plan was shown as primary insurance until after calling BCRC.
  5. Call Benefit Coordination and Recovery Center at 1-855-798-2627 to discuss with an agent and answer 5 or 6 eligibility questions. NOTE: Medicare Part D is heavily regulated and the newly insured must call BCRC.
  6. Be patient to wait for the new insurance plans be “cross-linked” in the mymedicare.gov account. It took around 2 weeks to have the information updated.
  7. Be persist to educate pharmacists, as most people don’t really understand the procedures, and the difference for the insulin to be supplied under Part B DME rules (with tubed pump, such as, Tandem or Medtronic) or Part D (disposable type pump).
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