Insulin in pump billed as Medicare Part B not D

Since I use insulin in a pump, which Medicare considers Durable Medical Eqpt (DME), it’s billed as Medicare Part B, same as a pump is. I have Humana Medicare Advantage with Part D drugs. I’m ok with paying my 20% share of my insulin under Part B because I don’t get a vote. But I ALWAYS have trouble getting Humana to bill it correctly!

They ALWAYS begin the refill procedure billing it as Part D. Their software invariably tilts, they always tell me there’s a problem with my order, sometimes they even send me a letter saying I need a prior authorization for the refill before they’ll fill it and ship it. Invariably they get it right but they look so dumb! Once they even shipped it correctly and THEN I got the form letter saying I need the prior auth!

Does anyone know of a parts supplier that is also a pharmacy that I could get the insulin from as well as reservoirs, etc? That’d be dependent on Humana accepting them but it’d be something to consider if I knew who I might could use.

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For those of us with Basic Medicare and a Supplement plan, it is a huge advantage to have insulin billed under Part B DME. Medicare pays 80% of the cost and my Supplement pays the remaining 20%. no out of pocket cost for me.

For those of you on Advantage plans, it is a bit murkier. Many Advantage plans insist on billing for insulin under Part D and you have to do the math to see if would be a better option than Part B. The problem with Part D is the donut hole with can be expensive if you use a lot of insulin. You have to remember that Advantage plans are not Medicare. They are private insurance companies contracted to provide your Medicare benefits. They have to provide what Medicare provides but can set some of their own rules.

As far as I know, you will not find a supplier that will provide both your insulin and your pump supplies. I am not saying that something like that doesn’t exist, but most of us get our pump supplies from DME suppliers and get our insulin from pharmacies such as Walgreens, CVS, Krogers, etc.

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And some of us skip the whole hassle by ordering our insulin by mail from Canada and pay 100% out of pocket. The total out-of-pocket cost is far lower than the part D deductible and you can go with a really cheap Part D plan for your other meds and no more donut hole worries. I think my part D supplement through WellCare costs about $12-$14 per month. The same insulin in Canada is about 1/10th of the US cost so even with express shipping the annual savings is huge.

I have heard that some Walgreen pharmacies do process insulin as a part B. I have not experienced this myself. The issue is that it is PITA for the pharmacy because they have to take your pump information and keep submitting it occasionally.

rick

I have been getting my insulin for my pump from Walgreens for several years. It sometimes takes 5-7 days to complete the process. I think it depends on how knowledgeable the particular pharmacist is in billing Medicare part B.

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Which Canadian pharmacy do you use? Did you check them out using a website? I was trying to get an antibiotic as well as insulin.

I am not sure what you mean by the question “Did you check them out using a website” Before Covid, I was driving up to a pharmacy on the Quebec border to pick up my insulin as I could pick up a 1 year supply and the trip only took me 2 hours each way. When Canada closed its border for Covid I started using

I have placed 4 orders with Canadian Insulin so far, actually, my latest order is due to arrive within the next few days. Even though Canada does not require a prescription to purchase insulin, this company requires a copy of your US prescription to avoid hassles at US customs. Your insulin will arrive about 1 week to 10 days after you order it and will be packed in a foam box with ice packs. I order about 8 months of insulin in the Spring and Fall season to maximize their discounts and avoid the possibility of having the insulin freeze or bake during transportation. Your insulin will arrive USPS priority mail. You can call them at 1-844-560-7790 if you wish and they are very pleasant to deal with. My only complaint is that they do not accept AMEX for payment, only Visa or Master Card. Hope this is what you are looking for.

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Everyone seems to have a different set-up for insulin. So here’s mine. I get mine from my LOCAL Walgreen’s (not mail-order). It’s always covered by Medicare Part B, as it should be, since I’m on a pump. I generally have to assure my pharmacist that I’ve seen my endo in the past 90 days, and provide the date, but I don’t have to do any more than that. I know they have to jump through Medicare hoops each time, but they’re good at it and willing to do it.

They’ve also been enormously helpful the two times I found myself on a trip across the country without my insulin (one time I forgot it at home; one time we plugged in our Peltier-effect cooler backwards, making into a heater, and my insulin was hot to the touch the next morning; my wife didn’t divorce me, either [actually, she plugged it in wrong, not realizing the polarity of the plug]). I called my home Walgreen’s, and they quickly transferred my prescription to the closest store to me at the time, so no worries. (Since it was an extra vial, I had to pay list price–ouch!–but at least it was available.

–Keith

This thread is turning out to be very helpful. It’s giving me several alternative ways to get my insulin:

a) one vial at a time at local Walgreens, billed as part B by a friendly pharmacist; pay retail? I’d pay my 20% copay since I have a Medicare Advantage with Part D at $0 premium;

b) multiple vials from some place in Canada, that I could never drive to sensibly from South Carolina! :stuck_out_tongue_closed_eyes: so I’d have to get it by mail or equivalent;

c) at least consider the cost of switching to a Medicare supplement plan that would pay my 20% copay, instead of my current Med Adv plan that includes Part D, but I don’t think a Med Suppl includes Part D, does it? So I doubt that would be a good idea all things considered, not just insulin;

d) stick with what I’m doing now, because even when Humana gums it up they do eventually get it right and I always pay the proper amount given they type of coverage I have, so I’m not out of pocket any more than I should be. And I believe my 20% copay on my lower cost for a 90-day order by mail from Humana would work out to less than my 20% copay one vial at a time retail, but I’m not sure about that.

I think just knowing I can consider these alternatives is a win for me. Thank you all very much. I’ve always believed you win by KNOWING what to do. You also win by KNOWING what NOT to do. You only lose by NOT KNOWING what to do. That’s why in the end this is a win for me.

Of course, keep the dialogue going. I’m sure there’s still much to learn.

Thx again.

Chances are that changing to a Supplement Plan is not an option for you. Supplement plans can use underwriting to consider your application after your initial Medicare benefit period (usually the first 6 months of being on Medicare). As someone with insulin-dependent diabetes you would always be refused. A few states don’t allow Supplement plans to do that but most do.

You are right that a Supplement Plan does not include Part D and you would have to purchase a separate Part D plan.

A lot of people on Advantage plans do better when their insulin is covered under Part D. Those who don’t are those who use a lot of insulin and end up in the dreaded donut hole. Technically under Medicare, insulin for a tubed pump is covered under Part B. But as I wrote above, an Advantage Plan is not Medicare; it is a private company which has contracted to provide your Medicare benefits. So sometimes they can set their own rules.

Sounds like you are doing a good job of trying to understand your options.

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I am 10 years from Medicare. Why does it need to be so incredibly complicated?
Why can’t insulin just be insulin and set a copay for it.

Why does it matter if I’m injecting it or pumping it.

These rules are psycho. There is no point to it.

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It takes a while to navigate Medicare but mostly it works okay.

The DME rule that allows tubed pump users to get insulin through Part B is a huge benefit for those of us using Basic Medicare with a Supplement. But if the rule changed, you know that other people wouldn’t get insulin at no out-of-pocket cost. We pumpers would just start paying higher prices. It is still is ironic that Medicare rewards me for using an expensive pump with supplies while those using the more economical MDI route pay more for insulin.

Advantage plans work okay for those who don’t use a boatload of insulin. Plus there are Part D plans with price caps coming out of the Trump administration. In general the insulin problem with Medicare is the same as the insulin problem for people of all ages with diabetes.

The biggest problem IMO with Medicare is that most people don’t understand the choices they make when they choose their initial Medicare plan. I was lucky to know older people with Type 1 who educated me about Part B insulin and other Medicare issues for those of us with diabetes. That being said, I still pay more for my Supplemental plan than it provides me in benefits and not every senior can afford Supplement plans. There are many people with diabetes who are happy with their Advantage plans and others who are struggling and regretful about their choice. One complicated issue is that plans are different from company to company and state to state. (Actually Supplement plans are required to provide the same basic benefits but some provide more.) And then you get retirement plans and all sorts of crazy stuff.

So I guess it is complicated…

But so is all insurance and healthcare in the USA…

That’s some good info.
My current plan is not complicated at all.
I pay 20% for pump and pump supplies.
But at a discounted rate so really it’s close to 9% copay.
My insulin is computed for 3 months and I pay 30 dollars for that every quarter.

I have no choices, but also, that makes it super simple.

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Why does a medication that costs a patient $10 per month with a private company insurance but cost a person on Medicare $1,600 per month? It deals with an original medicare law that is not so applicable today.

I used rxcanada4less.com aka Mark’s Marine Pharmacy for the one prescription to bridge between FIASP going off formulary and Medicare eligibility. The shipment got stuck in Post Canada, probably due to a snow storm. Called Canada Post and they put in tracer for needed medicine. That got the shipment moving. The US side didn’t appear to have any order tracking.

I used Shoppers Drug Mart back when I was in Massachusetts and driving I-90 every few months. They didn’t stock FIASP, but a week advance coordination would bring it in.

Yes you are correct. Insulin administered via a pump is Medicare Part B (NOT Part D). I’ve been getting my insulin (8 bottles/90 days, approximately $1500/order total) this way from my local pharmacy (Tiffany’s Natural Pharmacy) for about 3 years. I have not had to pay a penny at all. Total insulin cost is covered completely by Medicare and Aetna Supplementary Insurance. No hassle.