Insulin and Part B Medicare

Does anyone get their Insulin via Part B Medicare ? No one in my area seems to know how to process it as well as be able to tell me the costs involved.

I current get it under Part D but Part B says it is covered under that section.

Thanks In Advance

1 Like

Do you use an insulin pump? Here is what Medicare.Gov says about insulin:

Medicare Part B (Medical Insurance) doesn’t cover insulin (unless use of an insulin pump is medically necessary), insulin pens, syringes, needles, alcohol swabs, or gauze.

Medicare prescription drug coverage (Part D) may cover insulin and certain medical supplies used to inject insulin, like syringes, gauze, and alcohol swabs.

If you use an external insulin pump, insulin and the pump may be covered as durable medical equipment (DME). For more information, see durable medical equipment.

Your costs in Original Medicare

You pay 100% for insulin (unless used with an insulin pump, then you pay 20% of the Medicare-approved amount, and the Part B deductible applies) and 100% for syringes and needles, unless you have Part D.

It is processed under Part B if it is used in an insulin pump. This is listed in the Medicare handbook. Good luck getting it processed. You should definitely try the bigger chain pharmacies. I've been having a hell of a time straightening out my insurance since I started Medicare last November. But I have an integrated insurance of CalPers (Anthem) and Medicare. Integrated in theory - excellent coverage but too damn many cooks. I am still calling and e-mailing to get reimbursement for the Part B deductible that my insurance (the Anthemn part) is supposed to pay for. I think I have extra hassles because of the integrated system. CVS didn't seem to have a problem with the insulin on part B part. My second renewal just this week went without a hitch and I got both my insulin and my test strips on Part B at no cost. I've found it helps to ask for a supervisor at my "secondary" insurance and keep following up with the same person. At CVS I also have "elected" one person as my representative when things get confusing so there is continuity. I also recommend documenting things and highlighting the info in the Medicare handbook for the pharmacy. It's sort of like everything about D: You have to do the work yourself because the "professionals" are highly incompetent!

In addition to the above I have had problems with approvals for two procedures I know should be covered. Medicare is very disorganized and all the companies they work with "code things" differently so nobody understands the other person's process. I'm glad I only work part time because dealing with this stuff is a full time job!

1 Like

I'm glad I only work part time because dealing with this stuff is a full time job!
You are right Zoe. I have no idea how people who work a full-time job get the proper coverages. My part-time job, since I have not been working nor driving due to my ankle injury and subsequent surgery, is: Making sure my prescription medicines and equipment are covered and secured at a reasonable rate; Coordinating the data and services I receive from multiple doctors, labs, medical agencies and practice groups; and, Determining payment plans for medical expenses and bills. It takes at least 8-12 daytime hours a week, and I am not even on Medicare yet.. If I was still working full-time, I would not have the daytime hours to do it!!

But I am blessed to have reasonable insurances, It just takes time and tenacity and to do the ( This is funny since I am in a walking boot)"legwork". TEEHEE

God Bless,

My Target pharmacy says they can bill Paart B. Have not tried yet as I do not start medicare until this coming summer. Others have posted that Walgreens processes through Part B. You might try them or CVS as the other post suggested.

Sorted this out with much frustration. To file for Insulin on a Part B the Pharmacy needs to receive a "CMS-10125 - External Infusion Pumps" form from the Doctor. After they got this my cost went to $0 / 90 day supply. :-)

Why don't all the pharmacies just tell you that and why don't the Endo's JUST provide it is beyond me.

Probably because every pharmacy is different. I never had to file that form. (Never even mentioned). I had issues though with them charging me for the deductible that my "secondary insurance" is supposed to pay. I'm still waiting since December to get reinbursed.

I have to say, since I started on Medicare last November, the whole system reminds me of nothing more than a Third World Country. I lived in Guatemala for two years and learned the difference between there and the U.S. was that in Guatemala you never quite knew the rules (or there really weren't any) which was very frustrating, but the good part was that everything was more flexible. I take it back Medicare has the frustrating part but not the nice flexibility!

If you get it under part D, do NOT tell them you have a pump.

Medicare reimbursement under part B is so low that pharmacies are reluctant to dispense insulin. They lose their shirt. I haven't found a supplier as yet.
Very frustrating.

I get my insulin from Walgreens through Part B. Medicare pays 80% of the approved cost. If you alsp have a Medicare Supplement plan that will pay what Medicare does not. You also have to be on a pumnp with a C-Peptide level below a certain percentage for it to be covered. Kind of a crazy rule that Medicare willnot pay fopr insulin if you injnect it, but will if it is pumped in. Go figure.
Approved charge means: FOr example let;s say the bill is $100 ( just for illustrative purposes) Medicared approved charge may be $75, there for they will pay 80% of $75. You may be billed the remainder of the 80% figure between the $100 originlly charged. Thay can also add a 15% extra chargwe to the balance if they do not accept Medicare assignment. So you would be responsilble for that balance. If ou have Medicare Supplement also, it will pay that balance and your out of pocket expense will be $0. If you have a Medicare Advantage plan, check with the plan to see how they handle it Medicare Advantage replaces Original Medicare. Your Red White and Blue Medicare card does not work with these plans.

Part B is a coverage for Doctors, Labs, Durable Medical equipment, surgeries etc. So if you do not have a Medicare Supplement plan you are at great risk for incurring huge medical bills if you experience expensive procedures for for a medical condition. The dollars can grow very large for such things as joint replacement, cancer, chemp, radiation, by-pass etc. Let’s say you incur $150000 in medical charges covered by Part B. Remember the 80% of the approved charge rule and think of what you may be charged if you have only Medicare without a Med Sup plan. It could run into 10’s of thousands of dollars you would be charged.

I am so happy to find this information. I saw the coverage on part b of Medicare but not sure how to process it. This was very helpful