Hi Carol. Lets see if we can help you get this straightened out with CVS or Caremark. Now isn’t a good time to switch to Walgreens, they are expected to close stores this year to prop up their stock price again. I’d hate to see you change then have all the Walgreens around you close a month later.
Are you trying to get insulin for your pump at a local CVS or mail order through Caremark? What do they say when you ask them to bill Medicare Part B for your insulin?
Just to make sure Medicare isn’t part of the problem…
Thanks for responding! I’ve been on medicare for a year and a half (not 18 years!). I’m 69.
My card does say Part B. In Massachusetts; I have a supplement plan which clearly states in their documentation that they pick up the remaining 20% after Medicare if used in a pump. They do this with my durable equipment without any problem.
I have a tandem pump and all my supplies are covered by Medicare and then the supplemental covers the remaining balance.
I’ve tried getting my insulin all sorts of ways. CVS store, CVS Caremark, Big Y. Every time they charge me the extra $35.00 no matter how much I plead that the insulin is for a pump and therefore should be covered by part B. They ALWAYS act clueless…saying no, it’s not a part b med. They act like I’m a fool.
I’ve called Medicare and they are clueless…I’ve tried calling my supplemental as well. I don’t understand how this issue is one that they act like they’ve never heard of.
It’s so frustrating that I need to reserve my mental energy on the days I can tackle the issue as it takes so many relentless phone calls.
I have been using Walgreens for Part B insulin for a pump without any issues. I had been using Rite Aid but they stopped dealing with Part B. I know Part B is extra work for the pharmacy people and doctor’s office needs to provide specific documentation. There had been times in the past that the person entering the order in the pharmacy system uses Medicare Part D because most things they deal with are that way. As for Walgreens, they purchased many Rite Aid locations so that expense may be hurting them. Locally, CVS has been closing stores in the area. I did look into mail order for insulin and other Part B supplies but Caremark does not handle Part B at all.
Being MDI, I get my insulin under Part D but I am curious about Part B. If you have a supplement on your Part B, I would understand that the supplement would cover the additional 20%, however, if you do not have a Part B supplement plan and need to pay 20% would it not make sense that you pay $35 per month under Part B which is the maximum a medicare patient needs to pay, rather than 20% of the retail price which would most likely exceed $35 per month? The $35 per month maximum charge is actually quite a bit higher than our average net cost as we are most, if not all, overprescribed to make sure that we always have insulin on hand and we skip a monthly insulin shipment from time to time which results in less than a $35 monthly average cost.
Couple of options when dealing with those that don’t know how to do their job… @Terry4 I saw you posted that you get insulin from CVS. Could you please ask the people at your CVS if they have any tips for @Orpy Carol since your store knows how to bill part B?
I assume everyone working at a retail pharmacy is overworked and underpaid. So I’d start the conversation by making your next refill request in person. If possible go when the pharmacy isn’t busy. Say you need a refill, you know it’ll take a day or two and you need it billed to Medicare Part B and your supplemental plan.
I’m a fan of the southern phrase “Bless your heart” if they give me any trouble. I’ve also used “I understand you don’t know how to do it. I’m willing to wait until you look it up in LearningHub (the CVS training system) or contact someone who can help you” No one would describe me a people person so I’m sure there’s a nicer way to do that.
Thanks for the prompt but I fear that my current CVS pharmacy insulin/Part B situation has degraded. For years, I received Medicare Part B insulin from a CVS pharmacy/pharmacist successfully. This CVS was located in a Target that has since closed.
A stand-alone CVS opened a few blocks away and they have now filled two 90-day insulin Part B orders but Medicare shows no evidence of paying the bill. I fear that the pharmacist is “papering over” this problem and is crutching the system. Since I am actually receiving the insulin that I need, I don’t feel I have a basis for complaint.
I will review the documents that you linked to and try to reach out to the CVS pharmacist and solve this persistent situation.
One thing that might be affecting your coverage under Part B and causing a charge at a Pharmacy.
Long’s here (owned by CVS) will bill Medicare for Part B, but they won’t also bill a supplemental. I got a small charge when I picked up something and I made them double check that it was under Part B. Sure enough it was billed under Part B. Digging into it further with them, is the fact that this pharmacy won’t bill a second insurance company, in my case my supplemental that picks up any difference I owe under Part B. I called my supplemental and they said a lot of pharmacies won’t bill a second supplemental and that I should send the bill to them and they will reimburse me. An extra hassle, but in my case right now I rarely get anything through Part B from a pharmacy.
Here I go again, asking a question I’ve already asked. I’m ready to order insulin again (I had quite a stash of it). Again, if anyone can tell me where, in Western Central Mass. (Springfield area) , they know of a pharmacy who knows how to process insulin for a pump as Part B of Medicare, I’d be so grateful. So far I’m pay the extra $100 for 3 month supplies where my supplemental insurance should be picking it up. It needs to go through Medicare part B then my supplemental. I’m so sick of this topic. Pharmacies continue to act like I’m clueless and crazy; and I have the documentation to show that I’m not.
Hey @Orpy, so sorry to hear this is an unsolved problem for you. Did you try asking your CVS to lookup the procedure to bill Part B in CVS Learning Hub? Someone else posted recently that they got the same problem fixed by talking to the pharmacist instead of the techs and cashier. Not sure why you think you don’t have documentation, I linked to it above. @biosafety-guy likes to reference a shorter version, the Medicare and You Handbook page 39 under the heading Drugs
CVS Learning hub? Is that what they use? Frankly I hate CVS but will use whoever to get my insulin. I’ve tried Big Y…they insist they know how and then they always say, sorry, we do Part D.
I tried CVS and they NEVER could get the billing right. My supplemental ins. customer service even got onto the phone with the pharmacy - no go. The pharmacist called CVS internal help line – their suggestion was to contact CVS in another city that apparently new the secret sauce to bill it correctly. I went to Walgreens, they knew how to do it. Not a perfect ride, a few hiccups but always straighten out. I checked every pharmacy in my area and Walgreens was the only one that knew the procedure.
I never paid for insulin at CVS, just kept insisting that it was covered and it was up to them to figure it out. They would finally give in and did not charge. But it was too painful to do that every three months. So, Walgreens.
Again, you wind up stuck between pharmacies that don’t do DME cuz it’s not a drug, and DME’s that won’t do drugs cuz they’re not DME. You absolutely can not do it through a mail-order service like CVS Caremark. You have to do it through a bricks-and-mortar pharmacy, but you have to deal with the actual pharmacist, not any of the intermediaries who do most of the customer point-of-sale interactions. The pharmacist needs to bump it up a level to whatever they call the office that handles Medicare. I don’t know from CVS but at Walgreens it’s called something like the Medicare Benefits Manager. That’s the person who can unlock this for you. They basically check with your prescriber that it’s for an insulin pump, and then they wave their magic wand over their keyboard and voilá, Medicare okays payment and you’re all set.
Just in case here’s the Walgreens Medicare dept. phone number: 888-281-0590. Thanks @Laddie for posting it. The number is the same one Walgreens pharmacies call and you talk to the same call center the pharmacies do. You aren’t talking to Walgreens, it is a company they contracted to do their Medicare compliance work.
I struck gold in reddit.com/r/WalgreensRx today where Walgreens pharmacy employees help each other. Here’s most of the process. You shouldn’t need this, no patient should need to know this, but since many people have problems with individual stores I’m going to put it here where it can be found next time someone has a problem.
Doc sends prescription to pharmacy. Prescription sig (directions) have to say for use in pump.
If this is your first time at Wags (Walgreens) staff may look up your Part D plan and process the prescription or they may wait for you to come in.
Go to the drop off window, say your insulin is covered under Medicare Part B, show your Medicare card and give them your supplemental insurance card. If they don’t ask for both ask them to verify the information on your profile. If they disagree about using Part B they can verify your insulin is covered by open up the Plan parameters button in 3rd party for Medicare part B. It lists every drug and under what dx it is covered.
Pharmacy info about the supplemental insurance: “They show up as MEDBCOB and all you have to do in make sure it’s scanned into Medicare plan before running it through.”
Ask for the prescription to be reviewed while you wait for compliance with Wags Medicare Part B rules. Better for them to contact the docs office now and for you to know the exact problem if there is one.
At this point they should order your insulin or pull it out of the fridge because Wags policy is (as of 2023) to fill the first time before getting the SWO (standard written order) from the doc. @Orpy has already verified her supplemental plan covers 100% of the Part B copay so under no circumstances should she ever give Wags money for insulin.
This is where it gets nuts for the people working behind the counter. At some point your prescription is going to pop up in a reject queue. There are 3 different ways for them to proceed. One: call the Wags medicare number and listen to the hold music to create a ticket to fax the doc a form Two: create a ticket by going to teamrx-pharmacy-billing and collections-request CMN (Certification of Medical Necessity aka SWO) form. Three: This seems the most reliable 3rd Party → Medicare/Medicaid → Medicare Part B → Procedures → Summary of Procedures: Printable Job Aids → Medicare Part B (PDF) → (under the section Standard Written Order Form) → Medicare Part B Reference Guide: Claims Documentation → scroll to bottom and all SWO are available to click/print and fax the form from the pharmacy to the doc.
The doc might fax the form back. If not someone at the pharmacy repeats the previous step. Maybe the same way, maybe not.
If the SWO is faxed back to the Wags Medicare dept. go to step 10. If its faxed back to the pharmacy they scan it into the patients profile by scanning it like a script and then going into options-image-save card image. Then they call Wags medicare dept. and have it reviewed.
Reconciling the $0 copay is a bit of a mystery. They have to manually code it each time to bill the copay to the supplemental. Dunno if this has to happen with you standing there or it shows up in the reject list again. There might not be any documentation for this and its just trial and error and memorization.
For refills the SWO has to have been received and processed correctly before dispensing. Every 6(?) months a new SWO is required.
TLDR: Between the Medicare office for Walgreens having high volume of claims to look through, sending forms to wrong faxes etc, and the prescribers just straight up not being thorough enough… If someone does not literally babysit the entire process, it’s going to drag out forever.
@DrBB Advanced Diabetes Supply and USMed are mail order DME suppliers that sell Lispro so in Carol’s case there are mail order insulin options if Wags doesn’t work.
I get my part B insulin from a bricks and mortar CVS. As Dr BB suggests, you need to find a time when you can catch the head pharmacist … at least until it is properly set up.
In my experience, most head pharmacists understand exactly what to do, to get insulin for a pump covered under Part B … but many of the “counter jockies” don’t have a clue.
Also, your endo needs to provide all of the proper details on the prescription. Secondly, my experience is with “original” Medicare plus a supplement. YMMV if you have a Medicare Advantage plan.
