Medicare & Insulin pump problem

Rather than ‘hijack’ another person’s discussion about a similar topic, I figured it might be more polite to post this discussion.

I went on Medicare last Summer, and got my insulin pump in August of 2010. I was told at the time that Medicare pays for the insulin used in my pump under part B. Now it is ten months later and I’ve yet to find a provider that will bill Medicare part B. I paid $183.19 out of pocket yesterday for a one month supply of Novolog.

Has anyone actually been fortunate enough to have Medicare cover the cost of the insulin for your pump, and if so, how did you get to that point? Of course I am now in the “gap” and I would appreciate any suggestions on how to save on prescription costs. I do have the opportunity to do the mail order through my secondary insurance, but they don’t bill Medicare part B either. I’m beginning to think there is no such thing as Medicare paying for insulin used in a pump.

Here is information on what Medicare covers for diabetes. Go to and enter "Medicare Coverage of

Diabetes Supplies & Services " in the search box. You then download the pdf and it has the info.

Here is what it says about insulin, on page 13.

Medicare drug plans cover injectable insulin not used with an insulin

infusion pump. Medicare Part B covers external insulin pumps and the

insulin that the device uses under durable medical equipment.
[underlining mine]

Call your Medicare office, or whoever is handling your Medicare, and ask them which places are approved for durable medical equipment. Someone is not advising you properly.

While in the gap, check places like K-Mart, Walmart, and other places that offer discount drugs. Also, get your endo involved. They have other Medicare patients. Surely they can help you.

If anyone knows something different, please advise.

I’m curious - does this mean that Medicare covers the cost of insulin better when it is used in a pump, than it does when it is injected?

It is my understanding that Medicare covers the cost of insulin when it is used in a pump. When insulin is injected Medicare pays a percentage and you have a co-pay based upon your secondary insurance plan. It is confusing so I might not understand it correctly.

I spoke with a Medicare durable medical equipment representative this afternoon and the nearest ‘provider’ they have listed is approximately 90 miles from my home. The drive to this city and back home again would not be cheap.

Does this seem fair to anyone? That someone that manages their diabetes using syringes (clearly cheaper than a pump and therefore saving Medicare a lot of money), is punished when buying the insulin that they need to survive?

I hope this isn’t correct. It seems only fair to me that if they cover insulin when used in a pump, then they should cover it the same when used with syringes.

If this is really the way it is covered, then that must have been a lobbying perk paid for by the pump industry.

Actually what happened was Medicare decided to start covering pumps. But just because you have Medicare it does not mean you have an Rx plan. So they started approving people for pumps who had no way to get their insulin. Kind of pointless to spring for the cost of a pump and have nothing to put in it! So they started offering insulin under Part D IF you have a pump. There may have very well been some lobbying efforts surrounding this but this was their excuse at least.

That doesn’t make sense. It’s similarly pointless to spring for the cost of syringes and have nothing to put in them. But syringes only cost $20 a year (at least that’s all it costs me since I re-use syringes), and a pump costs several thousand.

Clearly the effect of this will be that anyone who is eligible for a pump will get a pump - even if they don’t intend to use it. Which is great for the pump companies, but not so great for everyone’s taxes. This is really insane.

Most people don’t know this and Medicare certainly dosen’t do more than post their “rules” on their website but I can see how this could open up some shady buisness. I suspect that this is one of the reasons they make you see your Doc every three months. If you haven’t been doing this they will not send supplies regardless of what the Doc prescribes. I think most Docs wouldn’t want to continue to verify someone is on a pump if they are not using it as they could loose their ability to bill Medicare for being involved in the shady buisness. My problem with it all is silly rules like this are very wasteful (people sitting around “verifying” you still have Type 1 diabetes etc). Madness I say!

OK, so then its forcing people to use a pump when they don’t really want one. I’ve had T1 for more than 35 years and have good insurance and could easily get a pump without cost - I just don’t want one. But at least my insurance company doesn’t charge me thousands of dollars extra a year because I’ve decided to stay with syringes. If they did that, I’de likely have gone on a pump long ago.

I think you’re missing the forest for the trees. It’s pretty trivial to prove that someone has Type 1 diabetes - and it only costs as much as one lab test done one time. I don’t have any problem with that. But to force a huge incentive upon people to get expensive medical equipment they don’t really want is incredibly wasteful. And the only beneficiaries are the pump companies.

I agree with you that if Medicare covers the cost of insulin when used in a pump, they should also cover it when used in a syringe. It doesn’t seem at all fair to penalize people that choose to use MDI. I don’t have your experience as a Type 1 as I’ve only been diabetic for 8+ years, but I do respect your opinion.

I also don’t understand why I am forced to see my doctor every three months either. If I want to continue with the pump I have to see him like clockwork. If I miss the 3 month mark by 1 or 2 days …Medicare will not pay for the supplies.

A couple years ago, Medicare started requiring everyone to choose a drug plan - that is not optional so you won’t be paying more for syringes than a pump. You don’t have to pick supplemental insurance but you do have to pick the drugs - those plans average about $15 a month depending on where you live and which plan you pick. The cost varies by what plan you choose. My pump insulin actually cost me more for the co-pays for insulin pens.

Mayumi, I would call Medicare and ask them to help you find someplace you can get insulin. Tell them you have spent hours trying to find someone. I had my supplemental plan calling places trying to help me when I could not find anyone.

Here is the link to the page on Medicare - you can submit your claims on your own if you have not been doing that.

Not so much the one lab test that concerns me. Imagine the number of folks they have looking at month long logs to determine whether that person actually tested as much as the script for the strips are written for. These types of things that they do go on and on. Seems very wasteful to me. They could have ONE person looking on Ebay for people hawking strips and probably be just as effective (They do do this for WIC infant formula)

I have never heard of a sigle person that got a pump simply for cheaper insulin. As Kelly WPA posted above apparantly now you HAVE to have a Rx policy so I suppose the pump deal is a mute point now anyway. Majes me wonder why they still provide under DME then?