Medicare Coverage?

Type 1 and LADA
1

I use a DexCom G5 CGM and a Medtronic 630G insulin pump, both of which were supplied to me under Medicare coverage last fall, shortly after I first enrolled in original Medicare along with a part G supplement. Along with the CGM and the 630G was a Contour Next BG meter, which links with the pump, and test strips, all supplied by Byram Healthcare. When I tried to order more test strips at a later date from Byram, they told me they couldn’t supply them because I lived in a “competitive bidding area”. After a call to Medicare I learned that I could get them through a local Walgreen’s Pharmacy. After giving Walgreen’s all my pertinent information they said yes, they could supply me with the test strips under Medicare Part B and gave me three months worth of strips. Wonderful!

Walgreen"s has since called me and told me Medicare will not reimburse them, that I must get the test strips from the same place I get the CGM supplies. I then call Medicare to see if this is possible, and am told yes that should be possible. (Apparently, Medicare has suspended the competitive bidding process). I then call Byram to see if they will supply the test strips and am told I must switch to a Wave Sense meter if I want the test strips supplied by them and covered under Medicare. I wasn’t confident in the answer given by the Byram rep. so I called again and was told that Medicare would NOT cover ANY test strips for me. Huh? So, another call to Medicare, and after jousting with the contact for several minutes I was able to talk with a supervisor who told me that Medicare had turned down my request for test strips. They would cover the CGM, but not the test strips required to calibrate the CGM. So, just for fun, I made another call to Byram, and the person I talked to this time says they should be able to supply the strips under Medicare coverage.

I’m not actually in critical need of the test strips yet because I still have a couple weeks worth of strips left. But, will Medicare cover them? Or, must I pay out of pocket? If so, I need to find a meter with cheaper test strips and not test any more than absolutely necessary. Has anyone else had this issue of determining just what Medicare will and won’t cover? I’m confused!

2

Medicare changed how they cover strips for those using a CGM, late last year.

I was getting a large quantity of strips from Walgreens (as was my wife, both on medicare) when suddenly late last year we ran into a snag that took nearly a week to sort out. Medicare finally communicated the issue to walgreens–if using a CGM, ALL strips must come from the CGM supplier. So we called Dexcom to see if they could accomodate the extra strips and they said if we get an Rx from our doc it would work fine. Which it did–I called our endo to have his office fax a new Rx to Dexcom. In your case,work with your supplier and your doc. It was a simple fix for a vexing issue.

The issues you mentioned are ridiculous. Dexcom provides the Contour Next meter, which you should be using and those are the meters/strips that are covered by Medicare. Someone is giving you the runaround.

3

I’ve called DexCom and was told I needed to go through Byram.

4

I understand that, Dave
But those boneheads at Byram are jacking u around. Talk to a supervisor and see if they will get u the Contour Next strips, because those are covered by Medicare.

Didn’t u get a Contour Next meter with your first Dexcom shipment?

5

Those of us getting our Medicare CGM supplies directly from Dexcom are still getting the Contour strips. I am able to get 3 vials per month which is 5 tests per day. Those with suppliers seem to be stuck with whatever that supplier provides which is most cases is not Contour. I am no longer able to get additional strips from Walgreens which previously had a prescription from my endo for 10 strips per day.

I do fine with 5 tests per day while using Dexcom. I wonder what will happen when we Medicare people are switched to G6 which requires no calibration. But we all know that some test strips will always be needed because CGM is not always perfect. TBD.

1 Like
6

I’m going to bet that with a doctor’s Rx, you’ll still be able to get some strips, Laddie., I mean, my god, I get more than the “standard” 150 strips from Dexcom. I get double that while on the G5. There are times when a CGM isn’t working and they can’t expect u to not have test strips if a T1. I think there is far too much worrying about the future rules.
It may be tempting to forecast the future, but it does none of us any good when there is no information regarding said future.

1 Like
7

I recently got my Contour Next strips from RiteAid ((150/month) at no cost under Medicare Part B; however, my doc had to complete a special form once the initial prescription was denied.

I noticed Walmart has them for sale - a box of 35 for $19.

8

Interesting…I haven’t run into this yet.
It is entirely plausible that that Medicare has decided you have to get your test strips through a sensor supplier. People mentioned getting their supplies through DexCom. That option isn’t available to everyone. Assuming those people have Medicare, I will say it actually surprises me because Medicare typically requires that the supplies come from a third party (like you are doing). I can only guess that the same may not be true across the country. (In some things, Medicare is not totally the same across the United States).

Back with the whole competitive bidding stuff the “mail order” diabetic supply companies that received the contract would only work with certain glucose meter companies (and they would REALLY try and push the person into “Off Brand” meters) then, as time passed, they suppliers that had the contract started to fade away in offering the “Big Four” (Accu-Check, Freestyle, One Touch, or Contour).
I hadn’t heard competitive bidding was suspended but, even if it has been, most of the DME supplies are going to still not carrying the “big four.”

That being said, if you are unable to get your supplies from DexCom (this is something Medicare may be dictating) and you HAVE to use Byram I would start complaining to Medicare.

If it were me, this is what I would do:
From what I understand Medicare (DME or durable medical equipment) is split into four jurisdictions.
Jurisdiction A: Connecticut, Delaware, District of
Columbia, Maine; Maryland,
Massachusetts, New Hampshire, New
Jersey, New York, Pennsylvania,
Rhode Island and Vermont
Jurisdiction B: Illinois, Indiana, Kentucky, Michigan,
Minnesota, Ohio and Wisconsin
Jurisdiction C: Alabama, Arkansas, Colorado,
Florida, Georgia, Louisiana,
Mississippi, New Mexico, North
Carolina, Oklahoma, Puerto Rico,
South Carolina, Tennessee, Texas,
U.S. Virgin Islands, Virginia and
West Virginia
Jurisdiction D: Alaska, American Samoa, Arizona,
California, Guam, Hawaii, Idaho,
Iowa, Kansas, Missouri, Montana,
Nebraska, Nevada, North
Dakota, Northern Mariana Islands,
Oregon, South Dakota, Utah,
Washington and Wyoming
Each of these jurisdictions has a medical director in charge of it:
Jurisdiction A: Wilfred Mamuya, MD, PhD
wilfred.mamuya@noridian.com
Phone (701) 277-2789 Fax: Not listed
Jurisdiction B: Stacey V. Brennan, MD, FAAFP
stacey.brennan@cgsadmin.com
Phone (615) 782-4662 Fax (615) 660-5997
Jurisdiction C: Robert D. Hoover, Jr., MD, MPH, FACP
robert.hoover@cgsadmin.com
Phone (615) 782-4476 Fax (615) 664-5955
Jurisdiction D: Peter J. Gurk, MD, CPE, CHCQM
peter.gurk@noridian.com
Phone (701) 277-2603 Fax (701) 715-9485
(At least as of 2018)

I would contact the person in charge of your jurisdiction and I would say something like this:
Dear Dr. ?,

I’m am a Type 1 diabetic dependent on insulin who is currently using the Medtronic MiniMed 630G insulin pump and the Dexcom G5 continuous glucose sensor to monitor my diabetes. I have met Medicare’s criteria for coverage for both of these devices.
As part of my Medtronic insulin pump system I also use the Contour Next Link meter to monitor my blood sugars. This is the ONLY glucose meter that is capable of communicating to my insulin pump. As required by Medicare for use of the insulin pump and DexCom G5 I test my blood sugars using the Contour Next LInk a minimum of four times a day (you could say the actual amount if you want but NOT less than 4 times a day). I do not have DexCom G6, which is the only sensor that is FDA approved to be used without calibration monitoring so I MUST use a glucose meter and glucose test strips to comply with Medicare’s requirements.

Recently, I have run into trouble obtaining those test strips. I had previously obtained them through Walgreen’s but I have been informed that, since I use a continuous glucose sensor, I must obtain the test strips from the same supplier as the one who does my sensor supplies.
I have contacted Byram, who is my durable medical equipment supplier (DME) for my DexCom supplies and have been informed that they will not fill the test strips I need. I have been told that the only test strips they will provide are called Wave Sense. This is a problem. That meter cannot communicate to my insulin pump and it is essential to my care that I have that capability.
My understanding is that I have to use Byram for my Dexcom (and Medtronic?) supplies. There are very few DME suppliers that deal with insulin pumps or continuous glucose sensors so my option of suppliers is limited.

From what I understand there should be no reason why I can’t obtain the Contour Next test strips from Medicare’s point of view. Byram just refuses to provide me with test strips requested.

I have spoken with both Medicare and Byram and can’t seem to get a resolution. My testing supplies are getting low and I have a short time in which sort this matter out. I really need some assistance and/or direction in this. Is there a way I can continue to obtain my testing supplies through my local retail pharmacy as I have been doing or is it really necessary that I obtain them from the same supplier as my sensor (and pump?) supplies? If I can obtain through my local retail pharmacy then why is the claim being denied and the pharmacy is being told that it has to go through my DME supplier? If Walgreen’s can do it then how do we fix it so that they are doing it?

If I HAVE to go through the DME supplier then why aren’t they giving me the supplies I need? My glucose meter is part of these supplies. This particular meter comes either from Medtronic, or Bayer- the meter manufacturer- directly. It is not something that you can obtain through a local pharmacy since is strictly used in communication with the Medtronic insulin pump. How can they fill part of my “pump supplies” (though don’t use quotes in the letter) but refuse to pay for the other when it is all covered by Medicare and I have met the criteria for coverage?
Any help in this matter would be greatly appreciated. Understandably, I’m very nervous about this mess. I CAN’T run out of testing supplies. In addition to it not being safe or good for my health, without the supplies I can’t met Medicare requirement of testing four times a day to continue to qualify for the pump without test strips and I’m worried this will put getting my other supplies at risk of being denied.

Thank you again for your time.

Sincerely,

Joe Smith :wink:

That is a basic idea of how I would approach it.