Medicare Guidelines - How to navigate?

Hello, I’m Dave.
I’ve been an occasional reader of some of these posts for a short while now. Not sure I can contribute anything of value, but I may have some questions from time to time that some others may be able to help with.

About me personally: I was diagnosed with T1D in 1977 at age 24. Not what my wife and I were hoping for at the time of our first wedding anniversary. But, then again, there is no good time to be diagnosed with a chronic ailment. We were given a fair amount of misinformation by the well meaning nuns at the hospital where I was initially treated. My wife was told I probably had 20 good years of life. We were told any children we might have had a 50/50 chance of developing the same disease. Our personal research painted a brighter picture. Thankfully, 41-1/2 years later, all three of our children and nine grandchildren are healthy! And I’m doing pretty fair myself. My eyes are good (for a 66 year old), my kidneys still work, no diabetic neuropathy. I’ve made an effort to take care of myself as best I can.

I spent most of my life working in the building trades as a carpenter. I spent the last few years as a building maintenance supervisor. Given the type of work I’ve done, I couldn’t imagine myself wearing an insulin pump with tubing. About six years ago I decided to give Omnipod a try and found it to be a great alternative to multiple daily injections or a pump with tubing. But now, as of last month, I’ve decided to retire and have to deal with Medicare. Yes, my medicare part D will now cover Omnipods, but at tier level 4. I can’t afford the co-pay! It looks like I’ll have to go to a conventional pump with tubing. I HATE the thought of being tethered to tubing! In addition to that, my Dexcom is out of warranty and needs to be replaced. I’ve been making phone calls and sending emails to my Dr., his nurse, pump manufacturers, CGM distributors, and pharmacies, not to mention multiple calls and queries to Medicare! The stress is making me want to end my retirement and go back to work!

So, here’s my question: Does anyone have any advice for wading through Medicare guidelines and jumping through the proper hoops?

Thanks

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Welcome! I have an OmniPod and Dexcom, but I don’t use Medicare yet.

@Dave44 and others here may have some suggestions for you!

Hi, Dave! Welcome!

I’ve moved your post to a new discussion hoping more people will see it.

My son, Caleb, has type 1 diabetes and has primarily used OmniPod for over a decade. Caleb would never consider a tubed pump - he enjoys the freedom of tubelessness with his active lifestyle. I thought tslim’s slick touch screen would appeal to him when it came out, but no dice. The only reason he agreed to try a medtronic tubed pump is bc it was the only way to Loop and he was headed to Europe by himself and we both agreed that would be advantageous.

There were several things to adjust to - how to thread the tube through a dress shirt, how to remember to change the site without an alert, changing reservoirs and sites. It all seemed very foreign at first, but Caleb very quickly adapted. It was much smoother than either of us expected. He still prefers OmniPod, but being attached to a tube what not as cumbersome as we had imagined.

I don’t have any experience with Medicare, but others do and will hopefully chime in.

I just noticed another new member, @Ti-1, is new to medicare and pumping and cgming!

I’m on Medicare and couldn’t be happier., When we had employer-base insurance such as Bluecross, Blue Shield and others, we had more issues with coverage than we do with Medicare. And Medicare covering Dexcom CGM is icing on the cake. I can’t think of anything to tell you about “jumping through hoops” as the ONLY thing that I can think of that I had to do to satisfy Medicare, as a pumper, was to get an additional blood test, which was the C-peptide. No big deal, obviously as I always have gotten blood tests prior to each endo appointment.

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Call your Endo and Omnipods representative. They know how to wade through Medicare. My Medtronic pump supplies and insulin is covered under Part B Durable Medical supplies.

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I’m on Medicare. My endo contacted Dexcom regarding the CGM, they contacted me, we had a 10 minute conversation, a week later my initial supply order showed up. I’ve only been on it for a two months, so I’ve only had one month’s resupply. No problems at all.

My endo contacted Medtronic about my continuing on with my pump. He knew they would need a GAD or c-peptide test, so had that done. They contacted me, we talked for a few minutes to confirm my new Medicare and BCBS supplement information. I’ve yet to receive my first shipment, but expect everything to be OK.

Its taken a while for Medicare to process (or for Dexcom to bill) but everything was covered by Medicare and BCBS without any issues.

Best wishes

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Hi Dave. I switched from a MM pump to Tandem when I went on Medicare . I called both Tandem and Dexcom and between them and my endo’s office, I only had to get a Cpeptide and provide glucose logs. It took about a month to get my new pump, and only two weeks to get my Dexcom.
Medicare requires that you see your endo every three months in order to get supplies. My endo books my appointments for the entire year, so I don’t risk not getting an appointment in time.

The hardest thing for me was to find a pharmacy willing to learn how to bill insulin to part B. That,s a whole other story, but since that got straightened out, all my supplies and insulin are covered 100%.

Changing to a pump with tubing would probably just take time figuring out the best way to wear it.

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Yes, Medicare patients go every 3 months, if on a pump.

Pharmacy personel can be quite ignorant of the Medicare rules. I had an unbelievable (long story) issue with Safeway’s pharmacy regarding my strips coverage. Long story short, after about 3 months of them charging me, they had to refund me well over $300. My wife had similar issues with them not doing the paperwork properly so we move on to Walgreens. THERE, the issue has been a bogus $20-something “copay due” every time I pick up my 90 day supply of strips. I always have to tell them its a mistake–they go to their computer, type in god-knows-what and come back to the counter to tell me it’s now free. I just had to go thru that rigamarole with them yesterday. They never learn.

Medicare doesn’t consider omnipod to be DME because the pods are disposable. My understanding is that SOME part D prescription plans cover the pods for the first time ever this year. I was led to believe by an omnipod rep. that the copay would be very low with my Silver Script plan. Not true! Also, since omnipods are not DME, the insulin also must be purchased through part D, apparently with a healthy co-pay. It is also my understanding that the PDM controler for the omnipods are not covered at all!

Hopefully, this link will help answer some of your questions.

https://www.myomnipod.com/become-a-podder/insurance-coverage/medicare

Dave thanks for the information.

Don

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Boy! They (Medicare) get you going and coming every which way possible. Part B (with my supplemental) pays for insulin and test strips which go along with my use of Omnipod. Cost of pods are so expensive and even with my Part D under Humana, it doesn’t save me money. Clearly something needs to be done. :pray:

I believe that Medicare just approved the use of Omnipod. You may now be covered.

I used the Omnipod for a while several years ago & really liked it, but the Ins/co-pay $ ‘stuff’ made me switch back to MDI until retirement… The Tslim-X2 is fantastic, but the ‘Infusion/Teather-Cord’ makes me ‘uncomfortable’. ‘IF’ Medicare will cover the Omnipod, that might be a great thing!

Hi Dave, I have one suggestion for you that was given to me when I went on Medicare and found I was having daily battles to get my supplies covered. Call Medicare and tell them you want to talk to the Case Management Department. They are the ones who will help you with not having to jump through so many hoops. My suggestion is to call first thing in the morning, when they first open, and never call on Monday. If you can’t do that, be prepared to sit on hold up to 3 hours to get somebody to talk to! I have been diabetic for over 50 years, and they argued with everything I need, including the amounts, and we are still fighting every time I refill my diabetes supplies. The Medicare Handbook that they gave you when you signed up states that insulin and testing supplies are covered under Part B, at 100%, as long as you are on an insulin pump. So stand your ground and don’t let them beat you down. Best of luck!!

Thanks to everyone for your suggestions and encouragement.

I began this process with Medicare on July 2. I only learned of the need for a c-peptide test through either one of these posts on tudiabetes or perhaps from a pump rep. I spoke with on the phone. I went to get the lab test done on July 24. Wouldn’t you know, the lab misread the orders and only did a BS and failed to do the c-peptide. I learned of the error on the labs part on Aug. 14 upon my return from a 2 week trip. Went in on the 15th for another c-peptide test and spoke in person with a local rep. and trainer for Medtronics to make sure my request for a pump would be expedited since I will be gone on another extended trip in Sept. I’m Hoping I can get the Medtronics pump before then, but I’m not holding my breath. Meanwhile, I’m having to buy Novolog (Humalog isn’t on Silverscripts formulary, which is fine) and Omnipods on Medicare part D with what appears to be an 80% copay for the pods. (I won’t even try to explain the confusion that has surrounded the Omnipods with Siverscript, I don’t have the words or the patience)!

Thankfully, I’ve finally heard from Byram Healthcare that my new CGM will be on its way soon. I sure hope so, since my old one has become unreliable and is out of warranty.

In any case, I’m hoping things will smooth out soon.

Thanks again for your suggestions.

Dave

Dave, my best social media source for Medicare info as relates to diabetes (primarily Type 1), is a Facebook group called Seniors with Sensors. The group name comes from the years when we were all advocating for CGM coverage by Medicare. The group has morphed into a clubhouse for seniors to discuss various issues related to diabetes coverage, tech issues with CGMs and pumps, how to get insulin under part B, etc.

Hi Dave. I started on the Omnipod about 9 months before I hit the Medicare age. I don’t use a CGM with it though I could get a CGM under Medicare. My prior insurance wouldn’t cover a CGM for a T2 with or without a pump. I’m with you. I’ve only used pods and can’t picture dealing with tubing. But Medicare will cover the PDM cost every 5 years (might be fewer) under Part B as a “blood glucose monitor” (yes, really strange category - likely worst BGM on the market). As others have stated, pods are covered under Part D now. At some point I think the Omnipod system will get properly classified as DME under Part B. Who knows when…
You didn’t mention if you also have any Medigap coverage. I kept my prior insurance, BCBS, which is now my secondary coverage. I declined Part D. My BCBS covers the Omnipod as DME just as it did before I started Medicare. Even though Medicare denies it, BCBS picks up 100% of my pod costs as DME. PreMedicare I had 15% copay on pods. So beyond my Medicare and BCBS monthly premiums I pay $0 additional for the Omnipod system, insulin, and test strips. Biggest challenge was getting my local CVS to correctly code my insulin and strip Rxs as “crossover” bills. Took a month and lots of calls to get myself educated to explain to my small local CVS. I have other Rxs so my BCBS coverage is better than Part D for that too. I pay the same Rx copays that I did PreMedicare. Biggest shift is that with my pump use my insulin moved to DME with 100% coverage versus a previous $80 copay under BCBS. I have a second major surgery coming up and the secondary insurance is a huge help with that too. You might find that adding secondary or Medigap coverage, if you can may, be advantageous to your situation.

I have T1D and use a DexCom G5 cgm; I do not have a pump.

I buy test strips at my local CVS under Medicare. I complete an AOB (Assignment of Benefits) form for CVS annually. Medicare told me I could purchase any brand of test strips I wanted as long as I had a prescription for them. (Lancets are also covered under Part B.) Medicare is extremely strict about refills–it must be 90 days between refills.

I’ve been using a DexCom cgm for several years and waited until Medicare approved the G5 for coverage to try to upgrade. Medicare has some hoops to jump through to get a G5; I met all the criteria. I and my doctor provided all the documentation requested. The DME supplier contacted my supplement and said the cgm wasn’t covered and wouldn’t process a claim. My Medicare supplement also told me it wasn’t covered. After a couple months of this circus, I gave up. I researched other Part B plans and found one that covers the DexCom G5; I enrolled in this plan effective Jan. 1, 2018. My supplies arrive 2-4 days after I call in my order. DexCom makes a receiver strictly for Medicare (looks like the G4 receiver). Under Medicare rules you have to use a receiver, not a smartphone or watch and only one transmitter is sent out every 90 days. (I am not saying these are negatives, just sharing details). The Part B supplement I have covers a swipe screen receiver and sends out two transmitters at a time. This plan covers the cgm based on medical need, not by Medicare criteria–again, this is not a negative, just a comparison. Medicare plans vary a lot, You have to look at which plans are available where you live. I made a lot of phone calls to various plans to ensure I could get coverage for my DexCom items. The Part B supplement I have has a representative who handles only diabetes items; she is extremely knowledgeable and it’s a piece of cake to work with her!

I can’t address your question about Omnipod. Insulin is covered under Part D if you don’t have a pump, and it is expensive! The doughnut hole is achieved very easily. Being able to buy a 90 day supply helps significantly. I have had difficulty getting my doctor to order adequate amounts of insulin for that many days so it costs me even more. That part of Medicare is very frustrating.

It would be so helpful if Medicare published a detailed book or had a big section online about using Medicare benefits when you have diabetes. My CVS pharmacist and my diabetes educator have been the most help in wading through some of the Medicare maze. DexCom had all the info about Medicare coverage criteria for the G5, too.

I was diagnosed nearly 61 years ago. I refuse to say “I am a diabetic”. I am a person who has diabetes. I will continue to work on it, learn–and navigate insurance!

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