Medicare Part B DME insulin pump cost of humalog

Type 1 and LADA
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From what I can tell there isn’t a good answer to this because it is the pharmacy that has to submit the claim and survive the audit. It should just be this:

The Nuances Surrounding Insulin Prescribing

It is necessary to specify on the insulin prescription, “For use in insulin pump” to use the Part B pricing option.

In addition to the prescription pharmacies also have to obtain and file a Standard Written Order (SWO) so when they are audited they can prove the patient needed the drug they billed Medicare for. Like Durable in DME, Standard in SWO is ironic. As far as I can tell the SWO isn’t part of the claim submission, its just filed for when the pharmacy is audited.

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I’m glad some of you are successful at using Part B for insulin. When I first became aware of the possibility, some years ago now, I took my prescription to the local CVS, and was told, by the head pharmacist, that they could not deal with Part B. Knowing that people on-line were saying they used CVS, I then took it to another CVS, and a young pharmacist managed to fill it (I believe it took a long time and involved phone calls). But, when I tried for a refill, 3 months later, the head pharmacist came out and, not too pleasantly, refused it, while I watched the young pharmacist’s face go red in embarrassment. Then I tried a couple independent pharmacies, where one owner explained how they couldn’t run a business waiting for medicare to pay, but that he understood there was a young woman at a certain Walgreens that would deal with Part B. Ah, I miss Misty! She hadn’t known how, but it intrigued her, and she figured it out. I learned to order refills before calling the magic 800 number with each order, and explained it to the frequent new pharmacists. It was never a simple transaction, and the most recent pharmacist had never seemed to get it. And periodically, I would be told that I had to also buy my other drugs there. But I would get it eventually, paid by Part B and my supplemental, for quite a few years.

This year I had been using up a backlog I’d accumulated, and, seeing that there was again new staff at old Walgreen, went to a new Walgreens in walking distance. They didn’t seem phased by my story, but said they didn’t have any, so they would order it. Then, when I went again, they needed a preauthorization form. After 3 more trips to the store, 17 days later, with the Novolog (Insulin Aspart) still not in stock, they offered me my prescription back, and I took it. Novo Nordisk said there was no shortage on their end. So, I tried a pharmacy that my husband uses, in the grocery store we frequent – I think that pharmacist was just making up reasons as he talked. Which further raised the possibility in my mind that it was the Part B that was causing the Walgreens problem, though I don’t know that.

I ended up buying the insulin with Part D, at the friendly independent store where I get my heart medicine, 4 blocks away. I decided it was my present to me. At least this year. I gave her the prescription in the evening, I had the vials the next morning.

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Ok. The saga goes on. I did stop in person at a nearby CVS where I was treated like I was an ignoramus. I asked to speak to a pharmacist to discuss how to get my insulin through part B and then through my supplemental insurance. This guy was too busy and looked at my supplement card, saying there’s nothing on there to direct him (there IS my membership ID number). I had a copy of the medicare instructions regarding part B covering insulin for pumps and he basically said he couldn’t just believe anything that I had been mailed. In fact, it was a printout from the Medicare site. He did look up an order of mine from last year and said that they had put in through B. I said, but it didn’t go through my supplemental. Yaddi yadda. He ended by saying that I’d have to place an order for insulin before he could figure it out. I am really tired of pharmacies acting like I’m stupid. I can bet I know more about Medicare and supplemental insurance than he does. Re #6 point, unless I pay, I don’t get the insulin. They won’t let me walk out without paying. So, today I will call my supplemental and see if they can understand my situation. Last year, they seemed way confused even though it clearly states in my benefit handbook that they pay the remaining 20 % after Medicare pays the 80 %. This seems to be a nightmare that never ends and frankly, paying the extra $100 each time I get insulin is almost easier than fighting this.
I will also stop by Walgreens today to see if anyone has a bit of recognition about this issue. Help…

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How’d it go at Walgreens?

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I’m replying to my own message. I have FINALLY gotten a response from my supplemental insurance that I AM CORRECT! My pump insulin goes through Part B Medicare and then through my supplemental to cover the remaining. But how to get this through to CVS! According to my supplement info, it’s virtually impossible to get through to CVS, that actually Big Y (I had used them previously) had actually processed it correctly. I’m not saying this is over but at least I go a response that I’m not crazy, that CVS just doesn’t want to cooperate!!! Even my doctor started acting like things had changed, that I was wrong. But no, I am correct. As we knew.

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Did not go to Walgreens…it was getting too complicated. I stupidly went back to CVS and am awaiting the arrival of my insulin. Even my doctor is confused now, referring to my Part D formulary…which is incorrect. When the order comes in, I will be asking to talk to the person who deals with Medicare Part B and supplemental. If they can’t cooperate, I’ll cancel the order and go to Big Y where at least I was treated decently. See my other post.

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I will be making the transition from employer insurance to Medicare soon, so I appreciate this discussion!

BreakthroughT1D (formerly JDRF) has a guide on this subject and more (not just CGM) here: Medicare Coverage of Continuous Glucose Monitors (CGMs)

To ask a (maybe) dumb question: why so much focus on CVS/Walgreens? Has anyone tried Sam’s Club or Costco? Any mail-order DME providers in addition to USMed and Advanced Diabetes Supply?

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I’ve been struggling trying to get CVS to cleanly bill Medicare this year for pump insulin. They formerly supplied me for years without any problem. Starting in January 2024, CVS has yet to have been paid by Medicare under my Part B Medicare. After several phone calls to the CVS billing department (800-494-4287), I discovered that CVS has not formally billed Medicare due to their own recognition that they do not have all the data needed for a successful claim. They said that they are not short of any data from either me or my doctor.

I have received my quarterly quantity of Apidra vials (so far in January, April, July, and October) and did not have to hand over any co-pay. They understand that any claims not submitted within the Medicare 9-month requirement will be forfeited by CVS. They told me that their recognized claim data insufficiency is overwhelming their ability to submit claims to Medicare but that they are working to solve this problem.

Sheesh! I appreciate their candid remarks but their inability to take care of business surprises me. I have no basis to complain since CVS continues to supply me with my required Part B insulin and doesn’t ask for any co-pay.

I think CVS’s dysfunctional administration of Medicare Part B insulin is affecting many Medicare patients.

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A quick google search (now AI) shows that neither Costco Rx nor Sam’s Club Rx is qualified as a Medicare DME supplier. Is this consistent with the experience of actual customers?

USMed and Advanced Diabetes Supply are both Medicare DME suppliers. I use USMed for my Dexcom CGM supply which is covered as DME under Medicare Part B.

The seemingly over-focus on CVS and Walgreens is due, I suspect, that they are two of the largest Rx’s in the country and are both DME suppliers. Many of us who use insulin like the ability to physically pick up our insulin and bypass the vagaries of shipment.

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And never underestimate the degree to which Medicare staff themselves remain confused or ignorant of the pump-insulin provision under Part B. Over half a dozen calls I was repeatedly given conflicting information (up to and including agents telling me that I was simply wrong about pump insulin—“Insulin is Part D hon!”—and never got anything useable from them as to how you go about actually DOING it.

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I’m not sure in what part of this thread I left off. But recently I was able to get acknowledgement from my Health New England Supplementary insurance that they absolutely DO cover the remaining cost for my insulin used in a pump after Medicare Part B is charged first. But, how to get this to work! They DID look at my records and saw that Big Y (I had used them last year) DID process my insulin through Part B and it did get to my supplement (yet, I remember paying some money to Big Y). I had a serendipitous moment where I actually unbeknownst to me, talked with the CEO of Health New England who routed my situation to the proper channels and people. I’ll keep you posted as to my next order. I was also told that no formulary restrictions are needed. I really feel like this is an issue for our legistators but how to educate? I feel like I’m being denied a benefit I’m paying for yet with no recourse if a pharmacy refuses to cooperate.

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My sister told me yesterday of an amazing experience at CVS and I wanted to pass it on hoping it will encourage you to keep trying to get them to bill Medicare Part B. Her husband just had a lung transplant and she had to go to the pharmacy to pickup his meds to be ready for him to be released from the hospital. She was wary, an employee there has a bad attitude about controlled painkillers. Instead the person helping her said “I heard *** got his new lungs, hope he’s doing well.” Another employee came up and expressed the same sentiment. They had everything ready and there were no problems with the C2 meds.

There other thing my sister said that made me think of you is that it seems like every year there’s a new set of people working there. So eventually your CVS or Big Y or Wags will hire or transfer someone who can figure out how to bill Part B and HNE.