Lyumjev and Part b

I chose my Part D drug plan because they covered Lyumjev. I wear a pump and was unable to get Lyumjev through Part B because tandem had not approved it for use. Today optum Rx said it is not covered I have to go through part B. Did I miss something? Is Lyumjev now covered under Part B. They are telling me it is.

Looks like Medicare added Lyumjev to the External Infusion Pump Local Coverage Determination in the 07/01/2023 revision. I have read that part D claims for items that should be covered under Part B can be denied but I can’t find the text at the moment. The denials don’t usually happen because the Part B claims processing was separate from Part D but its only a matter of time until checks are implemented.

I can’t see where it says Lyumjev was added in your attachment. My part D is absolutely refusing to cover it, insisting I use Part B. Walgreen pharmacist said not covered under part B. On the phone with Medicare they said if it’s insulin and it goes in the pump it’s covered that they have no “formulary” in part B

I have been trying to get a printed copy of a Medicare letter saying YES

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Sorry Bobbie, I meant to post a link with a highlight like this: LCD - External Infusion Pumps (L33794)

They created a code specifically for claims for LYUMJEV used with a pump.

@DonR I’m not on Medicare yet but I can see the future. :sunglasses: Last month I went looking for a list of insulins for use in a pump that can be paid for under Part B. Short answer: doesn’t exist. Medium answer: Medicare doesn’t care but tasks the contractors who process claims with cost controls. I’m in California so I looked up Jurisdiction E - Part B - JE Part B - Noridian and found a lot of info but the actual “here’s what we approve” is locked in a black box.

Thank you. That’s very helpful. It confirms what I’ve found. There is no part b formulary for insulin. I don’t know where to take the fight to next. Apparently there is an appeal process. I feel like giving up and just going back on Humalog. I’m on Ozempic so Humalog may actually work better. But I will miss the rapid onset and shorter duration for sure.

That list and code with dates is so extremely helpful. Hopefully it will help me on my quest. Thank you! Medicare in general has been great for the three years I’ve been on it. This is my first glitch. My supplement cost is going from 140 per month to 175 tho the day after my 69th birthday this year. I’m going to seriously research Advantage plans this year.

Oh that would be so helpful

I sort of found a list of the insulins that can be billed under J1817 Insulin for administration through DME

Use this code for Humalog, Humulin, Vesolin BR, Iletin II NPH Pork,
Lispro-PFC, Novolin, Novolog, Novolog Flexpen, Novolog Mix, Relion

Plus the two other J-codes for Fiasp and Lyumjev.

The source for this is a PDF of a sample page of a coding reference book from Optum.