Medicare Part B insulin for pump

Went on Medicare + supplements (AARP for medical, SilverScripts/Caremark for drugs) in April 2022. I still haven’t been able to figure out how to get my Fiasp covered as Part B, which every source I can find, including Medicare, says is how it’s supposed to be done.

  • CVSCaremark (SilverScripts/Careington)*: "we just handle pharmaceuticals. We don’t do Part B/DME
  • Medicare: “We have no idea what you’re talking about. Talk to your doctor”
  • Doctor: “We sent Medicare a certification (not a prior-auth, they call it something else) and Medicare said they couldn’t accept it.”

I see where others have been getting their pump insulin from Caremark but having it charged to Medicare. Is that right?

I was given to understand I had to have my walk-in pharmacy order it and charge it to Medicare. Which would seem to work except that Medicare won’t accept the charge because they don’t have the right paperwork or something even though my Endo’s office sent them what theoretically they’re supposed to want.

Has anyone else fought their way through this morass, and if so what was the trick? Is there like a magical phrase I’m supposed to use to unlock the curse? Help! I thought this would be so straightforward! Is there something wrong with me???

I get my Part B insulin through Walgreens. Some pharmacies are better at it than others. I always get my Part B insulin but it is not unusual to have some glitches. Mostly they just ask for different information every 90 days.

Although I didn’t like how Fiasp performed in my Tandem pump, I did get Medicare Part B coverage for it.

My suggestion is to call the Walgreens National Medicare department and let them do the work.

(888) 281-0590‬

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The doctor has to submit cms-10125 form (google dme cms-10125) if the codes are not correct medicare rejects it.

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It does have to be submitted on a different form.

But a few notes. Only vials for pumps will be covered. If you use a pen to fill it, it won’t be covered under part b. You have an advantage plan? I do know they can be very different in what they cover. People have complained about that before.

Plus it’s possible if you have an Omnipod, I haven’t run into if insulin for it is actually covered under part b because it’s not classed as a part b pump. I couldn’t get past the pens aren’t covered for it to find out.

Medicare reps do know about the part b coverage, Maybe you just talked to someone that didn’t? I have found them very helpful and they have talked to someone else to find out information for me. Some instantly know things and others don’t. It probably just depends who you get, But if you do have an advantage plan, you might need to check with the advantage plan about coverage? I’m not sure how they completely work, except for people complaining that they don’t always cover things.

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I think that’s correct for the Omnipod Dash and, particularly, O5; it’s prescription, not DME. Consequently whatever you stick into it is going to be prescription too.

This may apply to Eros as well; Insulet did an end-run around the attempts to deny them access to Medicare by converting the whole shebang into prescription. This was done by giving the Dash PDM away, “for free”. With the O5 any legal argument is moot because the PDM is not required at all. More than that the Dexcom G6 (which is required) is also not DME because the Dexcom receiver can’t be used at all; the sensor is activated from the 'phone.

Of course the cellphone might be DME. Hadn’t thought of that before; anyone got a Samsung S22 on Medicare yet (it’s cheap compared to the previous arrangement, really cheap!)

Next year this gets to be a big deal for Medicare; next year the Insulin costs $420 for the whole year if it is prescription. DME suddenly becomes bad news.

It has to be a tubed pump to get insulin in medicare part B. A patch pump is filled as part D. The good news is that with the passage of the build back better pan insulin purchased under part B will also be $35.00 per month.

That insulin was originally excluded from the $35 provision but a recent Medicare decisions has instructed pharmacies that they should charge $35 per month. So for instance my bill will drop from $70 / month to $35.00 not later than January 1.

CMS has also said they will refund insulin purchases back to September 1 that cost more than $35.00 / month.

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Does this $35 per month apply to ANY insulin? Or is there a list of covered insulin? I am on Lumjev.

TUBED is not the key… The key is the pump must meet the standard for DME.

Standard Medicare will cover 100% after deductible.

Someone shared this Medicare document on Facebook today. Although many of us use the shortcut of calling tubed pumps DME, the distinction is really whether the pump is disposable as @Jay6 mentions. Currently tubed pumps (Medtronic and Tandem) are not disposable while the tubeless Omnipod is disposable.

I know a few people who have been getting Part B insulin coverage for Omnipod and this document clearly says that is incorrect.

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@Laddie That is interesting as it very clearly states disposable pump. I wonder if it comes down to costs? Once you have a tubed pump, infusion sets etc are cheaper on a tubed pump. The pods are more expensive and costs can be offset more in pharmacy benefits provided by an outside source versus paid for by Medicare under Part B. But distinguishing like that really makes you wonder about the Dexcom G7 CGM coverage under Part B in the future with the transmitter being tossed with the sensor.

@Sandreoli I have been wondering with the new law if they will still “cover” the more expensive insulins too. I use Afrezza and pay $50 for whatever amount I need. It’s a small difference, but a difference that can end up adding up with everyone that uses more expensive insulins. They say the $35 cap is on covered insulins. Which possibly means they won’t include all the insulins currently covered. Afrezza was a more recent addition as being covered on my part D plan. (last year)

Under my insurance before Medicare I still remember being switched from my regular insulin to a different one that was covered. My doctor was able to write I needed that particular one and it was okayed but at a higher price because it wasn’t on the formulary anymore. That would be fine for me at my $50 for Afrezza, but would it even be allowed to be covered at a different price at all if it wasn’t at the $35? It depends on what the law says and how it’s interpreted.

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The receiver is what has enabled Dexcom to be covered under Medicare, not the transmitter. Although most of us don’t use the receiver (although I use an approved “receiver pump” ( Tandem), the regulations are still that the receiver should be used occasionally.

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I use mine. For instance right now I am using it to make sure several books do not fall over. It is very effective.

According the commissioner for CMS, all insulin will have the $35.00 per month maximum. You asked about Fiasp and Lumjev and i do not know that answer. I did not ask the congressman I asked about $35.00 for insulin used in part B pumps.

Again the congressman specifically asked and was told that all insulin purchased since around September 1 and the person ad to pay more than than $35.00 per month will have the difference between what was charged and $35.00.

No I do not know that for certain. I did get the information from a congressional office.

But as a guy who bought insulin on September 2, I am hopeful.

@Laddie So that sort of now doesn’t make sense to me as Omnipod has the PDM? Or am I talking about apple and oranges in it’s different rules for the CGM versus pump rules for the “disposable pump” for Omnipod? Sorry … you just seem to know.

LOl, I do use my receiver, although I do turn it off at night… My phone is set at 130 for high and 80 for low during the day. My receiver is set for 70 low and 160 high. That way my phone alerts me first, and I respond if I think I need to. But if my receiver goes off I know I am either still climbing or dropping. A back up system for me.

@Rphil2 Afrezza is still listed as covered for me, but my plans goes Jan 1st to Jan 1st and they don’t change the pricing or maybe drop things until then. I don’t think the law actually requires the change until Jan 1st too.

I think Omnipod O5 has pdm, included free with starter kit. So insurance doesn’t actually cover it, and my guess as to why disposable O5 podds can be covered as pharmacy, non-DME.

I think user can use phone app or free pdm.

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I don’t think it makes a lot of sense either. CMS was under tremendous pressure previous to 2017 to cover CGM for seniors. And given convoluted Medicare regulations, DME was the only place that it could fit. It was a stretch of the imagination to say that the receiver had a 3-year life which is one of the requirements for DME. Why Insulet couldn’t claim the same for Omnipod doesn’t necessarily fit the puzzle. I have always heard that Insulet did a poor job many years ago with its submission to Medicare and finally grabbed pharmacy coverage when it was available. But I hated Omnipod so this is not my battle and I hope that CGM doesn’t eventually end up in Medicare pharmacy benefits.

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I, too, am on Medicare, and sounds like our insurance/supplement situations are similar. I get vials of insulin for my Tandem pump at a local CVS and it is covered by Medicare. The Rx label on the insulin box states that the insulin is to be injected via an insulin pump. It sounds as though there’s a coding issue for your prescription at the endo’s office. Check with your pharmacist–they may be able to assist you/guide the endo with the needed coding. I don’t have any knowledge about the cms form someone else cited—that may also be a necessity. Just wanted to share the suggestion of checking with your pharmacist. Good luck–and let us know how this turns out!

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The pump only lasts for 3 days; not 3 years. It’s a killer; it took Insulet years and years and years of lobbying to build up enough stash to have the CMS put in a category for disposable pumps.

NOTE: this is OT for the OP, who apparently has a 3-year pump, but it is completely on-topic for Omnipod users, regardless of variety, who have prescription pumps (like, it only lasts 3 days; some prescriptions last a month, my wife had one that lasted 90 days!)

Still the question for the MDI guys (OK, that’s also OT) how much does bolus+basal cost?

This CMS (Center for Medicare and Medicaid Services) web page has more detail that what I found on the Medicare web page. Scroll down and you will see “Model Drug.pdf” which lists the specific insulins it will cover. (I may not have inserted this link correctly.)

Everything I’ve read is that insulin covered with pump use under Part B is “unchanged”. All clear as mud.

Now to further add to the mud, my insulin for my old Omnipod is covered NOW under Part B and has been for years now. I pick it up at my local CVS. My GP sends the form to CMS quarterly certifying that I am using a pump. Don’t know on what basis some of the posters above say that this is wrong. I am certain my CVS is not sticking their neck out on my behalf.

Technology evolves. Medicare is way behind in dealing with that in Part B. What defines “disposable”? What defines “tubed”?

It is so difficult to pin down straight up answers. The kicker is that open season is NOW for making the best decision for each of our circumstances for 2023. Best wishes, Everybody!

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Dexcom is covered as DME with disposable sensors that only last 10 days. The receiver is considered to have a 3-year life and thus they have covered the whole Dexcom system as DME.

At the point that Omnipod was refused DME coverage, it had a PDM which could have been analyzed to have a 3-year life just as much as the Dexcom receiver. Now that Omnipod uses phones and lock-down phones as receivers that probably cements its classification as pharmacy.

For many people on private insurance, pharmacy coverage can be cheaper than DME. But for many of us on Medicare, DME is the much cheaper option,

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Yes, and I’m sure Insulet argued that, yet it didn’t happen. Think about it.