Insulin and Medicare

Excellent summary, @Nolan_Kienitz. Thank you for posting this. We need to somehow pin or otherwise make your comment more sustainably visible. Your comments answer several questions that come up regularly here.

There’s so much confusion in our age group around Medicare vs. Medicare Advantage as well as the traditional Medicare Supplement plans that nicely dovetail with Medicare but not cheap.

Great description, great comment!

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Wonderful info. Would you be willing to share the cost?

We are on my husband’s plan he had before he retired and the cost is horrid plus we have Medicare A and B but the Enbrel for my Rheumatoid Arthritis is so expensive and Medicare does not cover it. My insurance pays about 4700 per month for it which I inject once per week. I could do an infusion at the hospital of another RA drug, which Medicare would cover completely but it may not work as well and I fear that the pain and damage to my joints if another drug did not work could incapacitate me…

If my husband leaves the plan for his diabetic needs I would have to leave also. So…scary.

We are still researching and I want to tell all of you sharing this info how thankful I am to you. I am very stressed about this and I feel a bit better.:woozy_face::smiley::two_hearts:

Wayne also.

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Sally,

In the USA (and very likely Canada) the only “tubed” pumps currently in production are those made by MedT (MedTronic) and the Tandem X2. Such pumps with “tubes” going from the pump to the infusion set on your tummy qualify for Traditional Medicare Part B (DME) coverage.

The Omnipod style pump is a direct connect device and is not approved for Part B (DME) coverage, but (as I already noted) was just approved for Medicare coverage under the Part D (RX) plans. As noted … not all insurance providers of the Part D (RX) plans have the Omnipod in their formulary. Even so … it is expensive and will push a user to the infamous donut hole in a heartbeat.

I’ve attached a link that provides an explanation between the Medicare Advantage and Traditional Medicare offerings. Traditionally people using insulin pumps and CGMs fare much better with Traditional Medicare and a Supplemental (MediGap) plan. Medicare A & B are “traditional” Medicare. Then you can add a Part D (RX) plan and a Supplemental (MediGap) plan if you like. Plan F is still available if you sign up like right now as it will no longer be available to ‘new subscribers’ as of 01/01/2020. Plan G will still be available for new subscribers and costs less per month. See comments below about that.

Enbrel is a drug and that is/would be covered under Medicare Part D (RX) plans. Again depending upon the formulary for the insurance company and that plan. It is known as a “specialty” so does cost far more. I’ve attached a link for some data about Enbrel and Medicare as well. The one article on Enbrel linked below provides another link into the Medicare.gov site where you can enter your zip code and do some more searching for education on Enbrel and Part D (RX) coverage.

The Enbrel will have absolutely nothing to do with you signing up for Medicare and Part B and getting a supplemental (MediGap) plan. Supplemental plans F & G are both the same, but the F plan has a higher monthly premium, but you do not have an annual deductible. Plan G (which is what I have) has the same coverage and a one time annual deductible of about $185.

With Medicare Part B (DME) and my Plan G all my doctor visits, insulin pump supplies and insulin and CGM (Dexcom G6) are fully covered at 100%. I still get to pay whatever percentages for the various RXs I have for blood pressure, cholesterol, etc…

The MedT 670G is an OK pump and ties in with the MedT CGM. Problem is that the MedT CGM has not been approved for coverage by Medicare. If you are considering a pump and possibly might add a CGM in the future I would strongly recommend getting the Tandem X2 pump. It is a great pump and also will communicate with the Dexcom CGM G6 device. AND … AND … they are both fully covered by Medicare.

As for Medicare Advantage … I would not entertain at all and that is due to my diabetes, insulin, insulin pumps, CGM. Also on traditional Medicare I can pick/choose my Endo and all other doctors. The MA plans are like the HMOs in the commercial world. You typically have to use the doctors and facilities in “their network” and often those networks are very limited.

In fact many doctors and hospitals won’t accept patients with MA plans. So be very aware of such. They often spin a good line, but I don’t trust any of them.

Link for Medicare Advantage & Traditional Medicare explanation:

Enbrel Cost under Medicare Part D (RX)
https://medicareblog.org/enbrel-cost-with-part-d/

Best of luck. Hopefully some of this will be helpful to you.

Cheers,

Nolan K.
North Texas

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Tnx Terry. I’m not sure how one would create a document and pin it to an area for future review.

Sometimes that can be counter-productive as often questions and circumstances vary quite a bit. Albeit … some things are quite consistent.

Maybe the bookmark tool would work?? However … it appears it just pins the first post in this thread.

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Hi Nolan. Again Thankyou for your time and kindness.

The link to the info on Enbrel is 5 years old as I saw it upon research I did my self but it is a good representation of how much Enbrel costs except it is even more now.

Some secondary insurances you can tap into with Plan G and Plan D cost even more out of pocket.

Usually starting with January and February costing 1000 to 1500 or more and than high 200’s. So typically OOP 6000 or so per year. And there is no infusion option for Enbrel or I could go to the hospital and have it done there and it would be free under MPB.

They have you over a barrel. RA is an auto immune disorder that a RA drug may work for awhile and than nada or two or three RA drugs are combined. It is a very tenuous disorder to deal with. I know this is a diabetes forum however I am linked to my husbands plan as I mentioned and he is a diabetic. There’s more but just the nutshell. A quandary and a bit complicated.

Someone who is a Medicare specialist is researching the cost of meds if I go with G. I will let this group know the outcome as a point of interest.

Thanks again.:+1:

PS I believe the Medtronic is covered by Medicare. It is the sensors that are not. Terrible. Thanks for the advice about another pump choice. We are considering a change.:flushed::flushed::flushed:

Sally,

Remember that Medicare Part A & B and any Supplemental plan have “nothing” to do with your Enbrel RX. Don’t let anyone confuse you with that. If a Medicare Specialist is researching a Supplemental Plan (F, G whichever) for meds they don’t know what they are doing. They need to be researching Part D (RX) plans.

Unless they think they can magically make Enbrel a DME item, but that is impossible as one has to have a “durable medical equipment” approved by Medicare for such coverage. Drugs are not DME.

The MedT pumps are covered under Medicare Part B (DME). The 670G is the most recent and fancier pump that connects up with the MedT CGM product. But, as I mentioned the MedT CGM is not approved for CMS/Medicare coverage. Supposedly MedT is pursuing that approval, but nobody has been willing for over a year to forecast when such might happen … or even if MedT has presented their system to CMS/Medicare for consideration.

Also … you have “your” choice of devices (IE: insulin pumps). Don’t just take a doctor’s words for certain products. Often times doctors and other support folks get spifs to support a particular product and MedT has been known to do such time and again all over the USA. Just beware.

The MedT 670G with their CGM is reasonably good, but can be difficult to deal with sometimes (I’ve been told this time and again by many T1Ds who use their system). Also it doesn’t make sense to get that pump and not have the CGM covered by Medicare as well.

Again … there is a ton of information to try and absorb and chew on.

Cheers,

Nolan K.

Note that for new Medicare patients in 2020, Plan G is a high-deductible plan with $2340 being the deductible amount.

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I misspoke. I believe she is researching D but likes the G Medicare choice.

Yes the Medtronic is not perfect but we are doing ok with it. For now.

We are dealing with cataract surgery right now. My husband has a rare eye disorder so is lensless (is that a word?) :flushed::smiley: in one eye. Back and forth to Boston all fall and into the spring. We live in Maine.

We are quite the pair slogging along but at least we are together.

YogaO

8h

Plan G (which is what I have) has the same coverage and a one time annual deductible of about $185.

Note that for new Medicare patients in 2020, Plan G is a high-deductible plan with $2340 being the deductible amount.

YogaO,

Yes there is the new High Deductible Plan G that is being offered in additional to the traditional Plan G. Be sure you note that there are “two” options out there … not just one as that can create continued confusion.

Cheers,

Nolan K.

Excellent to hear that. I just get frustrated when so many of us (me included in time past early-on with Medicare) get led down a path where often I’ve found out the leader does not always know/understand the ins/outs of having to deal with T1D, pumps, CGMs, etc… And then you add other health concerns that further muddy the waters.

Just like YogaO providing input about the new high deductible Plan G Supplemental that is “in addition” to the tradition Plan G. I erred in not commenting about that as well, but the new Plan G didn’t impact me in my coverage this year so I didn’t even research a new Supplemental and my Medicare Specialist only mentioned it in passing and that I didn’t need to consider any changes … at least for this year. WHEW!!

Cheers,

Nolan K.

Thanks, my bad. I thought I had heard that Plan G was going away. Is there guaranteed issue with G, or are there medical underwriting questions?

Admins hope this is ok to post but what I received from a reliable source who assists people with Medicare. I actually volunteer for the organization.

If you sign up for traditional Medicare Parts A & B when you turn 65, you are eligible to add a traditional Medicare Supplement Plan, including the standard (subscriber pays the 2020 $198 Part B deductible, not the “high deductible” $2340) Plan G with guaranteed issue and no medical underwriting for a six month period triggered by your 65th birthday and sign-up for Medicare Part B. Here’s the reference from Medicare.

The best time to buy a Medigap policy is the 6-month period that starts the first day of the month you’re 65 or older and enrolled in Part B. For example, if you turn 65 and are enrolled in Part B in June, the best time for you to buy a Medigap policy is from June to November.

After this enrollment period, your option to buy a Medigap policy may be limited and it may cost more. Some states have additional open enrollment periods.

Hmm. I go on Medicare in a few months. I travel in an RV half the year so I’m hoping I can get me pump supplies and insulin without jumping through too many hoops

Hi Nolan. Do you or anyone know about coverage of Contour Next Test Strips and coverage of them thru Medicare?

Sally,

Once the paperwork inside the CMS/Medicare system got somewhat caught up Medicare stopped paying for my Contour Next One BG strip RX that my Endo had written. They were covered under Part B (DME) and my Supplemental.

The refusal to pay notice had a notation that said I was using a Dexcom CGM and due to that they (Medicare) would not pay for BG strips on top of paying for the CGM supplies.

I was getting my G5 CGM supplies from Dexcom directly and they also sent 1 to 3 boxes (of 50) Contour Next One BG strips with each monthly order of sensors. They were the only supplier to provide the Contour BG strips. Other suppliers provided other BG strips that their company had contracts with.

Due to the fact I’m on a tubed insulin pump with insulin all under Part B (DME) my BG strips also fell under that coverage path. In that regard an RX from an Endo for that specific brand strip should be covered under Part B (DME). If using an Omnipod or doing MDIs then everything falls under Part D (RX) coverage and supplies depend upon that insurance provider’s formulary. Not all of them have Contour Next Ones in their list.

So, bottom line, it is a delicate balance.

Now that I’m transitioning to the G6 CGM I won’t be getting BG strips as CMS/Medicare won’t approve coverage of RX’s for them when using that CGM.

I’ve read where some Medicare users are getting them covered (BG strips in general and not always Contour Next One), but they are having to jump through hoops and it certainly is not consistent. Will also vary as one has to ask questions carefully when people say “yes”. You need to find out if they are on a traditional Medicare coverage plan or Medicare Advantage. On top of that they are not always consistent from state to state.

It is a moving target.

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Terry,

In light of the changes in MediGap plans (especially the F & G plans) I reached out to a Medicare & Health Benefits Counselor that I’ve worked with for five years. He and I trade questions/answers quite a bit when it comes to Medicare and such.

I asked him specifically about the demise of Plan F and changes in Plan G. I’ve pasted his reply to me below. Makes it quite clear. I’m also thankful that it affirms that my original Plan G is not changing. The bold text is copied from my contact’s e-mail to me the other day.

Good morning! That is a good question let me extrapolate on that for you.

1. As of 1/1/2020 any “New Medicare Beneficiary” who starts Part B as of January 1st can no longer get access to Plan F, Plan C, or the high-deductible Plan F.

2. Plan G high-deductible is replacing the F high-deductible, it will be the same plan just different "name"

So there will now be “two” Plan Gs. One is the regular plan that I have and there will now be a high-deductible Plan G.

Thanks for this confirmation, @Nolan_Kienitz. I was concerned when I read @YogaO’s comment about the new in 2020 high deductible plan G. Like you, I chose Plan G as monthly premium savings easily paid for the annual Part B deductible.

My Plan G Supplement provider, United Health Care, raised my 2020 premium by 11%. I will be shopping for a replacement supplement provider next August and take advantage of the Oregon “birthday rule” that permits switching Medicare Supplement insurance providers without underwriting or any pre-existing conditions questions.

Any advice for identifying a good insurance provider? Perhaps I need to consider one that is priced a little higher now with the understanding that annual increases will not be aggressive.