Medicare and Part B insulin coverage


#41

Update, sort of. I am the one who is bugged by Dex website plus phone calls to Dex for monthly Medicare required orders vs my previous 90 day supplies.
My Dex regional rep is supposedly working to get me on email only orders, without phone calls. My conversation with her was over a week ago. And she says yes, Dex agreement with Medicare is q30 days not 90.
Overnight I got an email, telling me to go to the website to accept an order for a G6 which I did not order or want! I have a G5 and just got a new transmitter for it.
I have nothing else to say right now. Am so ticked. I will call later even though I know they are supposed to be open 24/7.
I have a busy day today so it will be evening (EST) before I will report my saga with Dex, between other activities today. Why are all the tech companies going anti-consumer now. Dex seems to be succumbing too.
And while I am whining, why is it that sometimes on tudiabetes, you can click on T1 technology on the upper left and other times you have to search for it in forums? There is sometimes a visible vertical left panel menu but it wasn’t there just now. And other times at random. Weird. Smile!


#42

I am so sorry for u that you are having all this trouble with ordering Dexcom supplies. Dang! I, for one, don’t want to be put on a G6 until after Medicare approves the software update to Control IQ for the T:slim, which in all likelihood will be my next pump. that approval may come in the middle of next year. A Dexcom regional rep warned me that if I get a t:slim now, I’d not be eligible for the Control IQ update thru medicare due to some arcane rules they have about updates and fees. It has been explained to me several times by regional reps and I still can’t wrap my head around the Medicare rules. Also, on the G5, I can’t even make use of a t:slim’s current Basal IQ feature. Medicare won’t even ship a Medicare patient a t:slim with Basal IQ. I need a spreadsheet to keep track of all the rules and caveats regarding when to get a new pump.


#43

Just talked with Dex. Two days ago a man from Dex told me I was getting a G6. Today, the woman I talked with told me I am not getting a G6!
I told her good, as I don’t want one.
The other good news is, supposedly now I have been switched to email only for my orders.

Dave44, thanks for telling me about the arcane Medicare rule as I had planned to pay out of pocket in January for a Tslim x2 to be ready for the whatever “communication” closed loop thingie.
My Medtronic 630 Medicare warranty won’t be up for about 3 more years. And I don’t want to wait that long for the night time protection of auto adjustment.
I must next call Medicare about whether they will pay for supplies if I get the x2 out of pocket when the time comes. It is things like this that make me wish to live in a country with universal health care. If not for family I would be in Canada.


#44

I’d call Tandem (sorry if I’ve earlier mentioned dexcom, when I mean Tandem) sales and ask for a regional manager. they know the rules “cold”. the salespeople know about 90-95% (in my limited interaction with them in my area) of what they should know about the rules. the regional manager seems more well-versed, AND better at communicating the various “gotchas” with Medicare and t:slim updates (basal IQ and control IQ). I’ve been getting quite an education and now prefer our communications to be via texts so that I can refer to the info they provide instead of relying on very lengthy phone call convos.

I’m so glad we didn’t just order a t:slim for my wife. it wouldn’t have the necessary software and according to Tandem she wouldn’t be eligible for even Basal IQ. At least that is the CURRENT deal. Hopefully, these rules get changed before summer 2019. (Besides which, she would need to be on the G6 to do even Basal IQ)


#45

My husband is with cvs but for some reason we can not fill his insulin over Medicare part b. Is there a certain requirement on cvs like does it have to have the urgent care with it?
Right now he sucks the insulin out of insulin pens from a friend who does not need it. I am so frustrated and don’t know what to do!


#46

I have problems to get insulin for my husband over part b. Do I have to notify Medicare ? I am confused! He has a pump and Dexcom sensors , but I have the problem to get insulin .


#47

The problem is likely the inexperience of the staff, if you are going to a pharmacy. I spoke to CVS a few months back, after returning to the CVS-Target pharmacy after more than a year’s absence (only because we received letters stating they couldn’t accept Medicare beyond 1 year past their taking over target pharmacies). We loved the experience of going to target pharmacy–close by and the staff knew us by name. Fast forward to a few months ago and I asked the new person in charge if we could get insulin via Part B and she didn’t think so. I came home, went to the Medicare site, printed out a couple of pages and returned another day to show her. She said it COULD be done, after all. So, my point is some people don’t know how to process Part B.


#48

Bridgette2, did your husband’s doctor certify to Medicare that he is using a pump? This must be done EVERY quarter. CVS will get a “no coverage” message from Medicare without it. I recently had insulin denied because my Doctor failed to submit the paperwork last quarter. I saw him in mid Sept. Then we had Hurricane Michael in North FL in early October. My home was destroyed and I relocated to MD. Many businesses in Panama City suffered damage and had no phones or internet for quite awhile. When I tried to get a refill in Nov at my CVS in MD, it suddenly said “no coverage” from Medicare. Once my Florida doctor finally filed the Sept report to Medicare on my pump use, I could get my refill. Took about 3 weeks to run this problem down. I was stumped at first as to why the sudden denial.

Only your doctor can certify to Medicare and it must happen every quarter to maintain coverage for insulin under part b for a pump. You can’t self certify and the pharmacy can do nothing.

Also check with your CVS and get the exact message as to why the claim is denied. If it’s “no coverage”, check with his doctor on the pump certification paperwork. If it’s a different message, you can share it here and see if any one else has experienced it.

You can also try calling Medicare with the denial message but be prepared to be on hold a long time and their answers are often very generic. Don’t give up!


#49

I wasn’t aware of the “every quarter” requirement myself, but I do remember that you have to be a pumper for Part B coverage. Good thing obxdiva added that info here!


#50

My husband is a t1d on medicare with a pump. We have gotten his Humulin R U500 through Walgreen’s last year twice then started getting denied because they are not a medicare certified provider of Pumps or Insulin. We live in Oklahoma. We were given a list of 32 approved providers within 200 miles and all that I have called do not sell insulin. I have been trying to get his insulin since Dec. 7, 2018 with no success. I have been on the phone with medicare advance resolution center and ARC?ARK casework team is to return my call tomorrow. I am so frustrated I don’t know where to turn next. Is he going to have to start using pens?


#51

Ginger, what about his doc? I’ve been getting my insulin from my doctor for at least 2-3 years, at each 90-day visit. He usually has enough samples to give me 3 bottles, sometimes more, sometimes less, each visit. Have you guys asked the doc’s office if they can provide insulin? I see it’s U500, but perhaps the doc has some?? Does his pump hold 300 Units of U100? If so, how long could a refill of his pump last if he switched to U100?


#52

Ginger7, I get my Humulin U500 for my pump under part B Medicare at my local CVS. There is a new twist on U500. Starting last Sept you can only get one vial at a time even though your Doc might write a 90 day or maybe in your case, a 6 month Rx. A new Medicare rule now says that no more than “13000 units at a time can be dispensed”. As you already know, U500 is packaged in 20 ml vials so this limits it to one vial at a time. If your pharamcy tries to fill a perscription for more than one vial, it will not go through the Medicare computer and will be denied. The pharmacy has to dispense only part of the Rx. Since you were able to fill his Rx last year and not now, maybe this rule change is a factor??

It sounds like you can get U500 pens but not vials? Walgreens is a big firm. Sounds odd that they would no longer sell U500 under Medicare. Maybe they gave you a list of 200 DME pump providers?? If they are pharmacies, surely some of them would sell U500 insulin.

IDK what ARC is but do hope they can help you. Don’t give up!!


#53

Dave44, Good idea but Lilly prices their U500 @ $1700 per vial. I’ve never encountered a freebie on those. Their pens are fairly new so samples are possible. Simply using more U100 for someone who needs U500 doesn’t work. Huge boluses are not absorbed consistently and results will be erratic. There are studies on geometry of boluses. I can’t explain the science behind it.

Using U500 in pumps is off label but based on my own experience, pumping is a superior to MDI. Insulet has a U500 in Omnipods study that should be wrapping up soon and am looking forward to those results. I started using 2/3rds less U500 after going on a pump and A1C went from 8%+ to consistently under 6% now. IDK what my body was doing with the extra insulin under MDI but obviously, I wasn’t getting the right amounts at the right time with shots before meals. I still bolus for carbs with my pump now but the results are so much better.


#54

ah, you must need a heck of a lot! thanks for the explanation. prices on U100 are also criminally high.


#55

I get my Insulin and test strips from Walgreens. Never had a problem because my Endo stays on top with required paperwork and the pharmacy manager is excellent with Medicare. I also have the phone number of Walgreens Medicare Supervisor to call as a last resort.


#56

Just in case I wasn’t clear, Don, when on the G5, there is a medicare “normal” number of strips they will provide for. For about a year, I was getting my G5’s from Dexcom directly, along with the “normal” amount of 150 strips /month. In addition, I was getting a lot more thru Walgreens, etc. That came to a halt in the fall of 2018 and all that I had to do was get a new Rx sent over to Dexcom. Otherwise, w/o a CGM, I would be golden to continue getting strips from a local pharmacy.


#57

My local CVS filled a prescription for 5 vials of Novolog. My prescription is for 40-50 units per day. But as I use only half of that, I don’t refill it often. But I keep it at that so that I do have a backlog. Right now I have four unopened vials and can refill it at anytime. I don’t know if it is legal to offer it to one of the furloughed Fed worker who are having problems getting insulin. I am in the Monterey, CA area.


#58

I can’t imagine you’d do more than 5 years of hard time in a federal penitentiary if you get caught donating a vial, Suzan. :slight_smile:


#59

I have been sending it to Africa with a doctor who goes there twice a year. also syringes etc. But if I find someone local who is having problems, I can donate some here. Just want to make sure that they really need it because I know that Africa needs it.


#60

Ginger, I had a lot of trouble with Walgreens getting my insulin for a pump. EVERY TIME I go to get insulin Walgreens has to call Medicare, tell them I’m still on a pump and then tell them that I have seen my doctor in the past three months OTHERWISE Medicare will not approve it!
And every quarter your doctor has to submit paperwork saying your husband IS STILL on a pump! Frustrating!