Insulin coverage on Medicare Part B … another gotcha at least at CVS

Type 1 and LADA
1

There has been significant discussion on this forum on the challenges of us pumpers getting insulin covered under Part B Medicare. While I HAVE encountered problems, I ran into a new difficulty today:

CVS told me that they could NOT transfer a Part B insulin prescription from one CVS pharmacy to another. For anyone with a vacation home or who travels a lot, this is NOT good news.

Pretty lame for a company with $250B in annual sales … but I thought I would alert you all to this so that you don’t get burned on vacation.

Happy pumping,

John

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2

Walgreen’s has told me the same. When I go to my doctor, every 3 months, I make sure I get a new Rx. It still takes a week to fill the Rx.
Not sure if the delay is caused by Medicare, Walgreens or the individual pharmacist.

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In the day and age of nationwide pharmacy chains and an honest effort to provide continuity of care, you might think that it would be preferable to transfer prescriptions rather than write them new every time. But no, evidently that’s not the way the actual law is worded.

“You are not allowed to transfer prescriptions for diabetic supplies and bill Part B. It is stated directly on Medicare.gov. Knowingly, doing so is considered Medicare fraud.”

4

This is been the rule at any pharmacy forever - they cannot do it - My wife uses a local pharmacy chain - does not matter who it is.

There folks at medicare/fda whose job it is to make things more difficult - call me crazy - I don’t care

5

the delay is caused by Walgreens, mostly. NOT Medicare.

6

Thank you all for your insights and comments. While Part B prescriptions for DME-related supplies would seem more likely to be transferred than “normal” Part D prescriptions and transferable prescriptions would, seemingly, make it easier to track fraudulent over filling of prescriptions, I guess I shouldn’t try to apply logical thinking to CMS rules.

Thank you all.

John

7

Under my prescription plan, I pay $50 for a three month supply of insulin (9 vials). Is there an advantage to ordering under Medicare Part B?

I mentioned this to my Walgreens pharmacist and she mentioned something regarding being reimbursed by Medicare for the copay.

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@Don1942:

I think that the short answer is that: “It depends … on a lot of things.”

Note: all of this part B stuff is only for insulin that is used in pumps that are classified as DME (Durable Medical Equipment) under Medicare and not for normal insulin vials or pens used for MDI. To complicate things, I understand that an Omnipod can either be DME or non-DME.

If you DO have a pump that is DME, then the insulin that it is used is SUPPOSED to be set up with a CPT part B code. As near as I can tell, however, 90-95% of folks using a DME pump, still get their insulin under their Part D (Prescription) plan … even though that is technically wrong.

If I am not mistaken, Medicare part B is supposed to cover 80% of the Medicare-allowed cost of a 30 day supply of insulin. (after, I think, a $195 annual part B deductible).

Some of the factors to consider include:

How good is your Medicare supplement plan? Will it cover some or all of the non-covered 20%? Will it cover your part B deductible?

Is your insulin of choice in the formulary?

How much insulin will you get for a 30-day supply?

Do you need to fill your prescription at more than one location? (Easy with a part D prescription … impossible with a part B insulin prescription).

Note: I think that everyone’s numbers are likely different and for some people, living with the Part D co-pay MAY BE cheaper than doing it the proper way … but, for SOME PEOPLE, their Part B insulin is actually free.

This probably takes some homework … and you may not want to ask your pharmacist if you already have a pretty good co-pay deal under Part D because going the Part B route may actually be more expensive.

After I have a chance … and after I pour myself a glass of wine because this stuff is crazy-making … I will try to post some of my specific numbers as an example. However, my numbers are simply my costs and calculations and your costs and calculations will likely be different than mine.

More later,

John

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The Dash, at least, is never DME under Medicare. Wish it was. There would be no donut hole, which will soon require me to pay 25% of the list price of the Pods & the insulin. Conversely, my Medicare Supplement C (which is no longer available to new subscribers), covers my deductible and the 20% not covered by Part B, i.e., everything’s free.

10

Its gotta be medicare. Walgreen’s switches my Rx around stores all the time. They offer to do it for me. I don’t ask, but if they think it will help, they always offer. It takes 15 min.

11

Please have your Walgreens’s staff train my Walgreen’s staff. :slight_smile:

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The biggest one is that the insulin doesn’t get counted towards reaching the donut hole and, if you do go in the donut hole, your insulin is still covered because it is paid through the medical portion.

13

I use Walmart. Medicare told me it had to be Walgreen’s or Walmart. How do you get part B Medicare coverage at CVS?

14

CVS would not run my insulin under Medicare Part B. I finally gave up and went to Walgreen’s, who, after taking my pump’s serial #, filled the prescription–no copay since I had already satisfied deductible. There is, as I understand it, a special prescription code for “pump” insulin (a rose by any other name . . . but I have given up trying to make sense of insurance as applied to diabetes). So I go back the next month (end of May 2020) and they tell me they can’t refill without another visit to Doc. I had been to Doc 3-1/2 months prior (and the prescription had 3 refills before April 2021), so what’s that about? And why would the Doc have written only 3 refills for a year? The prescription is written for 40 days. Why not 30 days? I am new to Medicare and really don’t get a lot of things. Now the Doc won’t see me because of covid-19, but he sent me some Humalog samples to the front door to get me by until next appointment. Does anyone notice any difference between Novolog (my usual) and Humalog? Someone told me CVS won’t put insulin prescriptions through Part B because they make more going through Part D. Can that be true? Does anyone understand any of this?

15

Medicare requires you visit your Endo every 90 days to be able to get your diabetic supplies. The 3 refills on you Rx is correct. You get 90 days with the original fill and 3 more refills to bring you to 1 year total.
I use Walgreens for insulin for my pump. I think it depends on the pharmacist you get, but I plan on a week before I receive my insulin.
I have used both and for me there is no difference between Humalog and Novalog.

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Form CMS-10125 needs to be submitted

The procedure codes that worked for my wife are J1817 and E0784

the endo should know this

If you get the form filled and get insulin be sure to keep a copy

She gets it under part B

You just need to find a place that will fill it under part B

17

Thanks for the info. I still don’t understand the logic behind my prescription, written for a 40-day supply (to be refilled only 3 times, 4 in all) good until a year later. 40 x 4 = 160, not 90 (3 months). Could I have filled the 4th?

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Yes, in my case. I have secondary insurance that picks up the balance of charge that Medicare doesn’t pay, so I pay zero for my insulin.

20

Two things: 1. I get insulin and pump supplies covered completely under Medicare Part B, no co-pay.

  1. I use Walgreen’s, local; they’re very good at setting things up. Moreover… a couple years ago I got caught on a driving vacation, about 2000+ miles from home, with no insulin (long story, involving my small portable refrigerator getting plugged in backwards, turning it into a small portable heater). I checked in at the local Walgreen’s, and they quickly transferred my prescription from New Jersey to Oregon; took about 15 minutes. Then I had to transfer it back when I got home, but there was no trouble there either. Walgreen’s seems to know what they’re doing.
21

Part B will allow me to get insulin (FIASP) without paying Part D premiums. I’ll be using tricare/military/VA pharmacies for everything else.