Great to hear, Terry, and I’m glad for you!
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It is always encouraging to hear a positive thing where Medicare is concerned. Happy that the process went quite smooth for you.
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It took me 7 months to get my insulin covered under Part B. This is because no matter how many times I told the pharmacist at CVS at Target that it gets filed under Part B, they were filing it under D. I complied with every single thing they asked - in fact, had my doc twice send an order with diagnostic codes, handed them an original RX on paper - but nothing budged. Every time I went for months, they would tell me about my copay.
I spent three hours one day calling CVS , Medicare, Tandem, Solara, and my supplemental insurance. Aside from referring right back to each other, Medicare said I was approved to have coverage under “B.” My supplemental agreed that Medicare was supposed to cover it under “B”, so that left someone at CVS as the blockage.
This pharmacy staff normally really takes care of me, very caring, very prompt, and helpful - but I finally blew up, let them know how angry I was about this, and that finally did the trick. One pharmacy tech took it on herself to resolve this issue, and she followed through with each step – and finally, about four days after she took that on, I got a call from her to come get the insulin. When I picked up the insulin, the pharmacist said to me “This is good to know because we have other diabetics on Medicare who pay that Part D copay. I can let them know Medicare covers it under Part B when they are on a pump.”
The moral of this story to me is clear - it’s not enough that I’m a strong advocate, I need to have someone specifically take on any case where there’s something messed up. In the end it was CVS filing it incorrectly, and this tech correcting the error with lots of calls and faxes.
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I am glad your persistence finally prevailed.
I know that I benefitted from people like you who came before me. Thank-you!
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I just can went on Medicare in March and use Kroger for Rxs. I knew getting insulin billed under part B would be a hassle, but luckily, the pharmacist, even though unaware it could be billed as durable medical, was willing to work with me. Medicare wouldn’t tell the pharmacist or the doctor’s office the correct billing codes. The pharmacist jokingly said he didn’t have the magic decoder ring.
I finally got so fed up that I called one of my Senators and spoke to the person in her office dealing with Medicare issues. After he agreed to advocate for me a week later, the pharmacist was able to bill the insulin and my BCBS paid the ither 20%.
I received a call from a woman at Medicare giving me her direct phone number and she told me to call her if I had any more problems. My Senator’s office also told me to call if I have more problems and they’d advocate for me again.
All of this took almost a month, but I knew it would be a hassle and had hoarded enough insulin so I didn’t run out.
I’m not aware of any changes by Trump, but it sure wouldn’t surprise me.
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My recent claim was delayed a few days due to a missing billing code. You were smart to solicit help from your Senator’s office. It’s amazing how whatever the impediment was cleared up like magic! I really think some bad actors are involved in messing up these transactions. My Part B strip claim at Walgreens was screwed up by a “medicare department” at Walgreens headquarters. Medicare itself was not to blame, something the local pharmacy tech led me to believe. Once I got past the word confusion and asked to talk directly to this Walgreens department, the strips were released.
By the way, I am a T1D using a pump to deliver my insulin. The code on the prescription label is: ECD-10 E10-8. An NDC code is also printed on the label: NDC-00088-2500-33.
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Good communication, any communication is totally nonexistent today, especially when responsibility is diluted among corporate people. No one is held accoutable, therefore no one takes it upon themselves to do anything to ease or solve the situation. (The above saying was gifted to me by a very smart lady, I cannot take credit for the content.)
I find that with CVS, it almost always pays to keep running it up the chain until you find someone to take ownership. If/when you get denied with this method, it can also help to ask for the denial and reasons for denial in writing.
All this is massively painful, IMO and just speaks volumes to the fact that “the system is broken”.
In @Laurie12’s example, when you have to get a Senator/Congressperson’s staff involved, that’s just an “Amen!” to the broken system. The legislature should legislate and perform oversight …
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Luckily I got this done for my wife with little effort compared to others here. Took about a month with the Lady at the pharmacy doing most of the work. Had to jump thru a few hoops but got done quickly - then that lady left and the next billed it wrong. But that got corrected quickly. The system is beyond broken and will get worse because repukes love misery as long as it is not them or theirs.
I’m not on Medicate yet - but that concerns me – my endo has my diabetes coded as E13 (Other specified diabetes mellitus) instead of E10 (Type 1 diabetes)… The description is set to Type 1, but that ICD-10 code is likely to make trouble down the road…
When you get to Medicare you will have to take a c-peptide test to qualify for pump supplies. Fortunately CGM coverage is easier. You need to be on MDI and various other qualifications. I don’t know that the diagnosis code makes a lot of difference.
My last c-peptide was 0.2 – Unless they change the rules, the requirement is based on C-peptide levels below the insuinopenia level as follows: " C-peptide levels will only be considered valid when a concurrently obtained fasting glucose is ≤ 225 mg/dL. Insulinopenia is defined as a fasting C-peptide level that is less than or equal to 110 percent of the lower limit of normal of the laboratory’s measurement method. Alternatively, for patients with renal insufficiency and a creatinine clearance (actual or calculated from age, gender, weight and serum creatinine) ≤ 50 ml/minute, insulinopenia is defined as a fasting C-peptide level that is less than or equal to 200 percent of the lower limit of normal of the laboratory’s measurement method. Levels only need to be documented once in the medical records."
Apparently, there used to be a ‘Type 1 designation’ requirement (c-peptide<0.5) but that was removed in 2001. The other requirements in the earlier document (1999) included 6 months of MDI prior to insulin pump with documented self-adjustment and either HbA1c>7.0 or frequent incidents of hypoclycemia seem to have also been removed.
I had a similar experience with CVS. We kept after them and kept insisting that I didn’t have to pay the Part B deductible. Finally now, things are working almost correctly. I still have to pay CVS the deductible but 2 months later, I get a check in the mail for that amount.
My local Walgreens now bills it correctly for me. After an incorrect biilling one time, I started putting a note about billing to Part B every time I place a refill order online.
Walgreens has some issues with their computer system.
My file is in their computer twice. People have tried to delete the duplicate for five years. No one has ever been able to do it, although I sense that some people have come close. They will always report all my Rx’s are many years expired and refuse to refill.
BEST SOLUTION for fixing most walgreens problems in one strike:
1.) Always have your doctor report that you need twice as much insulin as you actually use. My Doc reports that I use something like 5 times as much as I actually do and that prevents a lot (but, not all) of insurance company refusals to cover.
2.) Always have current paper records on a magnet on your fridge for all your Rx’s. If you have a terrible, walgreens specific failure, you may be able to fill it at another pharmacy.
3.) You have to keep track of the dates of expiration on the RX AND the number of refills remaining. Walgreens will not refill the Rx automatically, so when that Rx expires, you will not have access to insulin without Doctor approval (which can be difficult or impossible to obtain sometimes in a pinch).
4.) Always have backup insulin. Refill when you have one bottle remaining.
There will be problems, but these things will help more than anything else.
I am on Medicare along with me secondary insurance Blue Cross Blue Shield. Because I do have plan F, I do not have to pay for insulin used in my insulin pump. I haven’t had a problem with Walgreens other than having to present my BCBS card when I do get a refill.
I think there IS a disconnect Medicare part B, Part B and RX plan of supplementary plans. When I read all these helpful replies I get lost with all the abbreviations. Is there a glossary somewhere. What is CCC? I do all the suggestions to keep track of everything with Walgreens and I still have problems. My doctor reports my usage for more than I use but I only half of really what I need. I can’t get it fixed but won’t give up trying. The next move for me is to have my lawyer to write a letter to Medicare Part B and supplementay plans and make official claims.
Medicare Part B claims do require persistence, especially when setting up. Here’a document that covers Medicare diabetes supplies, including Part B info.
Here’s a publication that comes out once per year about Medicare in general. It has a section called Definitions that may help answer some of your questions.
I searched this thread for any reference to, “CCC,” and found none, except yours. Where did you see this term and what was the context?
You may also want to check out the state health insurance assistance programs (SHIP) in each state. These services are provided free of charge and are independent resources.
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Thank you for your reply. CCC came from reading this site. I do tons of research on line. I have read Medicare requirements on what is covered. I have had several on line chats with Medicare and the wording replies are the same as what I read. I know and have learned how approvals are made but there seems to be a catch somewhere on why there are sudden changes in my case. I am approved and 3 months later I am not approved. My doctor has sent his forms in a timely manner. Then, after 5 years with the same prescriptions nothing. With your input I will continue to figure this out. This is so stressful and the costly.
Thank you again. I will read and use what you sent. I really appreciate it.
Barbara
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