Medicare Part B DME insulin pump cost of humalog

I did a quick search and didn’t see anything new re: this so forgive me if I missed it. I recently went on Medicare and also have a supplement and Part D prescription plan. I’m being told that I have to pay $35 a month for insulin. I had thought that insulin in a DME nondisposable pump was completely free. But I’m being told that because I have part D it goes through that. This from the medicare chat person who seemed to know less than I. I’m in Massachusetts and would love to hear from someone who knows about the topic of part B coverage of insulin versus part D. While $35 won’t kill me, it adds up over the years.

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I have Medicare Part B and a supplementary policy. Insulin costs me NOTHING. I had trouble finding a pharmacy that would bill it under Medicare Part B. Apparently, the pharmacy makes more money if they bill under Part D. I finally found a small pharmacy that was willing to bill under Part B and have been with them for the last 18 years. It was quite a hassle. Insist. Or shop elsewhere.

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I did go over my supplement documents and it SHOULD pay the excess. I have chatted with Medicare and my part D plan which is SilverScript (I think now CVS Caremark). I don’t care who pays the $35 copay. I will not give up on getting this straightened out.

Can you let me know if the small pharmacy you use is Stop n Shop, etc. or is it special to your area?

cw

@Orpy

I have not paid anything for my Part B insulin either. Between Medicare and my supplement, they cover anything. I get mine filled at CVS.

However, as very few prescriptions are covered by part B, it often takes several tries to get it processed properly. I gather that it involves a different process than “normal” part D prescriptions.

Usually, if you can speak to the head pharmacist, they usually know that Insulin used in a pump SHOULD BE processed under part B.

Good luck.

John

Thanks! I did fill through CVS and got 90 days but still got charged some. The pharmacist was wrong in telling me that there’s a deductible. As of July 1, there isn’t.

i believe my supplement will cover the extra. What a pain in the butt…ironing all of this out.

Carol

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I had this same problem at least 5 years ago. There was one CVS pharmacist assistant who took the time to figure it out - so I kept going to him. But for the last few years insulin for my pump has always gone through Part B with no problem. After all, it is a DME (durable medical equipment) and your pump won’t work without it.

Is it required to have Dr write RX specifying insulin is used in pump to be Part B?

Yes, if I remember correctly, the Dr does have to specify that the insulin is for use in a pump that qualifies as DME.

I vaguely recall that someone on the forum wrote a nice summary of EVERYTHING that should be included. I will try to do a search and post a separate link if I csn dig it up.

Good luck.

John

I’m still struggling with this issue. No one I talk to seems to have a clue that my supplemental insurance covers the remaining $35. At CVS they couldn’t even find my supplemental insurance with the card I had. If anyone else can give me some pointers as to pharmacies in Western Massachusetts that they use I’d be grateful.

John,

She called with all the specs…they keep insisting on running it through my Part D prescription plan when it should be going through Medicare B and then my supplemental insurance (Medigap) should pickup the $35.00 I am SOOO frustrated.

Carol

As everyone has pointed out, if you have a pump and a prescription for insulin that specifies that it is for pump use and the insulin comes in vials then it should be billed against part B and will cost nothing. Humalog (and Novolog) U-100 vials are covered. You may have to shop for a pharmacy (or pharmacist) that will do the proper paperwork. If it was billed through part D then I don’t believe you can get any coverage for the $35.

I switched from U-100 Humalog to U-200 Humalog in my t:slim X2 because the pump wouldn’t deliver enough basal insulin at night (I programmed it for 3.4u/hr and it limited it to 3.0u/hr). U-200 is only available in pens and part B only covers vials so I’m stuck with part D at $35/month.

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Make sure that your doctor’s prescription specifies that the insulin is to be used in a insulin pump. Ask your pharmacy to use the billing CODE for Part B, not Part D. If the pharmacist doesn’t know, ask s/he to check with someone who knows.

If your pharmacy doesn’t want to do it, change to another pharmacy. I uses a Ralph pharmacy, it is part of the Kroger Pharmarcy. The Medicare Part B approved insulins include Hamulog, Novolog, Fiasp and Yumjev. I have tried all these four type of insulin and choose to use Yumjev in my Tandem tslim X2 pump.

I will continue to hammer at this issue. I’ve done all of the above suggestions. I was advised by someone on the phone to use a Durable Medical Equipment place but do they also ship insulin??? I keep going in circles and I can’t believe that no one has the correct information. I suspect the new insulin cap is also confusing things. OMG.

Carol

The Medicare rule is if you’re on an insulin pump, your insulin goes through part B, along with your cgm sensors. If you’re not on a pump, it goes through Part D. $35/month is the cap.

Kind of an old topic now but having gone through this whole mess two years ago when I started Medicare it might still be worth sharing my experience. Apparently you’re just supposed to be born already knowing this because I couldn’t find anything anywhere as to the specifics of how you go about it, who sends what documentation to whom etc.

No, they do not. Conversely mail-order prescription services like CVSCaremark can’t charge anything against Part B as DME. Insulin is a pharmaceutical, period, as far as they’re concerned. Thus, my first two-pronged roadblock when I started. Well, WHO then? Called Medicare 3-4 times, and got 3-4 different answers, all basically clueless.

Them: Insulin is a pharmaceutical, hon, I don’t who told you this.
Me: It’s on your website, they just don’t tell you how to DO it!
Them: Just because it’s on the website doesn’t mean it’s true.
Me: I know for a fact I am NOT the only person in the world who gets their insulin this way!
Them: Sorry, can’t help you

What finally finally FINALLY cracked the case for me was making myself such a PITA at my local Walgreen’s prescription counter that I got bounced up to the actual pharmacist, who then called the “Medicare Benefits Manager”—not sure that’s the exact job title, but something like that—and THAT is the person who contacts your prescriber and certifies your script can be charged as DME/Part B. I get a 3-month prescription and it seems it has to be re-certified every time, but it’s fairly routine now. Just don’t wait until you’re out b/c it takes a day or two.

It’s not enough that the script notes it’s for an insulin pump; there has to be some kind of behind-the-scenes handshake for the person at the counter to be able to charge it to Part B. Presumably CVS has a similar mage who can wand-wave it through for you. But it has to have some kind of official imprimatur; neither the counter clerk nor the onsite pharmacist (if any) can do it on their own say-so.

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Hi, do you know if Insulin Lispro (generic Humalog) is covered for a pump as well?

I do not know. “covered” sounds like an insurance question.

Hi @Mrs_Otto Welcome to Tudiabetes. Lispro can be paid for by Medicare Part B if you, your doctor and your pharmacy meet all the requirements.

Are you new to Medicare or having trouble getting insulin? Use the +New Topic button at the top right and tell us about your experience. Context is everything when it comes to Medicare.