Medicare Guidelines - How to navigate?

What is the coverage for insulin if you are Not On a pump?

From what I read is that you need to be on a pump for Medicare to pay for insulin. Not sure why but it is a good question.

If you are not on a pump, your insulin is covered through your Part D drug plan or the drug part of your Advantage plan. It is usually Tier 3 Preferred Brand Drugs and Non-Preferred Generics.

My understanding is that Medicare part B only covers insulin if you are on a pump, so you would need to run your insulin and diabetic supplies through your supplemental coverage.

Does this Tier 3 rule apply to Type 1 ? I hope not. This doesn’t make any sense. I do not use a pump ( have tried both MiniMed and Omnipod) but had too many issues since I’m allergic to adhesives. And yes, I tried many different tricks of the trade, before I gave up. My A1C is still between 5.8 - 6.0 without a pump. I have had Type 1 for 56 years and never worried, untill now, that my insulin would be unattainable. I’m nervous about going on Medicare next year.

Hi Dave- I have been on Medicare for just over 1 year. I was diagnosed with T1D in 2006. I have used the Medtronic pump and sensor for about 8 years. Medicare covers the pump supplies but not the sensor. I like the “Threshold Suspend” feature of the 530 G pump.
Back to Medicare: The rules are absolutely crazy. I cannot refill supplies until I have only 10 days of supplies left. They must confirm this every time. Visits to the endocrinologist and the associated blood work must be done twice as often under Medicare. (Every 3 months instead of every 6 months when I was 64 years old.). Also, I have to record on paper my BG readings from my glucose meter to confirm that EVERY day I tested the exact number of times as the test strip prescription requires. So if the prescription says test 7 times per day and on Monday I test 5 times and on Tues. I test 10 times, Medicare will not pay for the refill of the prescription for some/all supplies. I have to submit this written record every 6 months to my endo. Then the endo must sign and date the written report from me. When the report is submitted to Medicare, there are actually employees who count the number of times you tested as stated on the report.
And Medicare allows 3 BG tests per day. If the endo prescribes more than 3 test strips per day, he/she needs to justify why the patient needs to test more frequently. If the endo does not respond to meet Medicare regs, Medicare will only cover 3 test strips per day.
I have gotten the supplies I need so far, but it continues to cause a lot of needless aggravation and stress. I currently get test strips through my secondary insurance because Medicare repeatedly rejected the prescription for 7 test strips /day from my doctor.
Good luck.

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Gail12 - on my plan, Silverscript, the tier does not differentiate between T1 & T2.

Tier 3 pricing (2018) for Novolog U100 is $44 for a 30-day supply, no matter how many vials your doctor prescribed. No sure how much it increases when you get in the donut hole.

Is Silverscript a supplemental plan? Are you required to submit a daily log?

Silverscript is one of many Medicare Part D plans. It’s just the one I chose during open enrollment last year. But the costs are often comparable from plan to plan.

If you are Type 1 and use a pump your insulin is paid through Medicare Part B. If you do not use a pump, for whatever reason, your insulin goes through Part D if you have it.

And no, you are not required to submit a daily log.

What would be the approximate cost if you had Part D in Medicare for insulin? My husband is NOT a pump wearer. He does have the Dexcom6. He should go on Medicare in a couple of years.

Thank you!

JS1 - it’s going to depend on the Part D program/company you choose. Mine is $44 per 30-day supply until you hit the donut-hole.

Medicare open enrollment for 2019 starts October 15. I realize that you won’t need Medicare for a few years, but you can go to the website on October 15 and run a comparison of different Part D programs/companies to see what the costs would be now.

You would have to dig a little - click a link to download the drug formulary for each one to determine which tier the insulin you want is in- but its not exhausting.

Best wishes. If you would like assistance come October 15, please let me know. I’ve become a pro at this due to necessity.

For me, Novolog costs $35/month under part D with Silverscripts/Caremark at the local CVS pharmacy. I am currently using it with Omnipod which is not considered DME by Medicare. ( I expect to be switching to Minimed 630g by the end of the month so it should then be covered under part B). (I HATE THE THOUGHT OF TUBING! Sorry, I had to add that).

By the way, regarding your husband using the Dexcom G6, Dexcom told me that Medicare will only cover the G5, but not the G6.

Heaven help anyone who has to go on Medicare!!!

If you are covered by Medicare but do not use a pump, insulin, syringes/pen needles are covered by your drug plan or Advantage Plan. Test strips and lancets are covered by Original Medicare or your Part B supplement. (If you purchase test strips and lancets using your drug plan, the cost of these counts toward the Donut Hole, which, if on insulin, happens fast enough!)