For the first time since going on Medicare it looks like I will need to switch my prescription drug plan (Medicare part-D, not Advantage) to another company.
The insurer I’ve been with will no longer cover the Humalog (or Lispro) that I use in a pump. After major effort I have located an alternative carrier that will
cover my Rx’s but like other companies requires “Prior Authorization” when it comes to insulins.
I’ve been on a pump for 18 yrs and have always had employer and then Medicare coverage and never had to deal with this regulation. Am I at risk of denial of coverage? Is transitioning to another carrier a smooth process or are there booby-traps?
I can attest to the fact that Novolog is totally compatible with the Tandem pump. I’ve used it for years and both Medicare PartB and my insurance pay for it, so my cost is zero.
I definitely prefer Novolog over Humalog. Too bad that Cigna only pays for Humalog. I will start Medicare next year and I will look for a Part D plan that pays for Novolog.
Fair enough. I was just quoting Tandem’s inf. I’m curious; you’re getting Novolog covered under part-B. I’ve known for years that part-B technically covers pump insulin. But back then the pharmacies were not getting adequate reimbursement from Medicare and would not honor part-B billing. Has something changed here? Have you seen others insuring Humalog/Novolog under part-B instead of part-D? Thanx.
I could not find a big pharmacy to bill under Plan B. However, a small pharmacy in my tiny town was willing to do so. For those using fingersticks, They, too, can be billed under Plan B. There have been others here who have been successful in getting insulin covered under Medicare Plan B. Maybe they will speak up and tell of their experience.
I have, for many years, had Medicare cover my Apidra insulin that I use in my pump. It’s covered under Medicare Part B as part of the durable medical equipment (DME) provision. I’ve used the local CVS pharmacy and found that not every pharmacist knows how to fill out the digital forms.
Just today, I visited the new CVS store location that took over the clientele from a closing location. The new pharmacist knew about my existing insulin Rx that has been billed under Medicare Part B.
Medicare provides an 80% payment of an approved price and then my Medicare supplemental insurance policy is automatically billed for the remainder 20% amount. Like @Willow4, I pay zero out of pocket.
As far as I know, you can select whatever brand insulin that can be used in your pump. The Medicare Part B DME insulin is only covered for durable pumps. In other words, it will not cover insulin used in disposable patch pumps like Omnipod.
Thanks Terry4
Yes, I’ve known about the Part-B/DME/pump insulin thing for many years. But as alluded to in a previous post the federal reimbursement rate was set back in the ?1960s and the cost had risen like 10x since then. The pharmacies were going broke filling those Rx’s and later refused to do so. After learning that, I never even tried to use the part-B for insulin.
But now with that $35 price cap maybe things have changed. I would love to move my Humalog out of private insurance, more-so for stability of coverage than anything else. Every year we go through this musical chairs crap of changing drug prices, coverages, formularies, deductibles, premiums, eligibilities, etc. #*(!&%>$;+!!! Since I’m basically starting over again with drug coverage I’ll give part-B a try. Thanks again for the comment.
The meteoric price rise of insulin in the U.S. over the last 15 years or so, in my humble opinion, is mostly artificial. The very same insulin is sold at a fraction of the price just across the border in Canada - at a reasonable profit I suspect. If there was no profit in the sale of insulin to Medicare patients, big Rx’s like CVS would not be in the business.
It’s probably true that pharmacies make more money selling insulin under Medicare Part D Rx plans than Part B DME. Part B insulin is a small fraction of the transactions at the pharmacy. Due to this, many pharmacists do not know how to make the claim. Combined with the economic incentives, many just claim ignorance.
Make sure that your doctor specifies in the initial Rx that this insulin is to be used in a durable pump. I’ve even had the CVS pharmacists ask me the brand name, model number and serial number of the pump I’m using.
I’ve found that if the pharmacy fills other Medicare Rx’s, they can learn how to file a Part B DME insulin claim. In fact, politely insisting helps the community of pump using diabetics. Plus, getting out of the private insurance arena removes all the changeable factors that you cite. It’s a breath of fresh air!
Here’s more info about identifying if a pharmacy can file a Medicare Part B DME insulin claim. From the official annually produced Medicare & You booklet:
Durable medical equipment (DME)
Medicare covers medically necessary items like oxygen and oxygen
equipment, wheelchairs, walkers, and hospital beds when a Medicare-enrolled
doctor or other health care provider orders for use in the home. You must
rent most items, but you can also buy them. Some items become your
property after you’ve made a number of rental payments. You pay 20% of
the Medicare-approved amount. The Part B deductible applies.
Make sure your doctors and DME suppliers are enrolled in Medicare. It’s
important to ask your suppliers if they participate in Medicare before you get
DME. If suppliers are participating suppliers, they must accept assignment
(which means, they can charge you only the coinsurance and Part B
deductible for the Medicare-approved amount). If DME suppliers aren’t
participating and don’t accept assignment, there’s no limit on the amount
they can charge you.
