Medicare Part B insulin for pump

Except for an Omnipod, which doesn’t have the 90 day visit requirement.

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@Marie20 , @Laddie ,

In regard to the DME standard from Medicare. An integral component must have a life expectancy of 36 or more months. The Omnipod PDM does not fulfill that requirement.

In relation to insulin for pump, the patient must be on a DME pump. A pharmacist and patient were charged and arrested for Medicare fraud in 2021 for billing insulin as DME when it was going in a Pod. The story thread was a Medicare audit detected DME insulin when no DME pump supply claims were submitted.

@MM1, there is a difference in the price of a starter kit, so the PDM is not FREE. The O5s are covered under Rx by most plans, however, the PDM is a non-covered item.

Thoughts?

If a local pharmacy can accept and bill Part B for insulin, it should come up on a search Medical Equipment and Supplies run from medicare.gov.

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The former answers about non-disposable and the correct form are also what I have found. However, mostly it has been how up to date and informed your pharmacist is. I had one Walgreens pharmacist tell me I was being “snarky” because I brought him the written Medicare ruling. I went to a different Walgreens where they took the time to call the Medicare Intermediary and got 5 bottles for 90 days for $0.00. I get all my pump supplies for nothing as well.
Now that insulin is under the $35 ruling I would think the Omnipod 5 would be covered for that price under Part D, but there was no such ruling at that time so Lyumjev had a large co-pay if using disposable equipment.[quote=“Laddie, post:15, topic:90685, full:true”]
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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Mine has been sitting in a drawer for a year, since I got the Tandem. Do you think I will get caught? :rofl:

I use mine every day. That book has never fallen over.

The pump is a DME receiver.

By way of an update, a recent interaction with a helpful (!) Medicare customer svc rep provided a useful bit of insight about why this whole process has been so full of unstated assumptions, inadequate patient documentation, and blank stares from various parties I’ve dealt with trying to get it straightened out.

Basically it’s because at the start Medicare isn’t set up for my situation and what I thought would be the way to do this. My situation is that I already have a pump and am just trying to get the insulin for same covered as DME, which IS supposed to be a thing. But it’s not an à la carte thing they way I imagined it. They envision all your DME stuff as total reset when you switch over to Medicare coverage. All of their procedures presuppose starting from zero: requesting a pump, having your Dr certify the medical necessity, getting Medicare approval, making the purchase, and everything proceeding within the system, including setting you up to get your consumables, insulin as well as reservoirs and insets, all as part of the process. If you are coming at it like I did, just trying to get the insulin for my (old) existing pump covered, it’s like coming in through a side door where you keep bumping up against people who didn’t have a clue what you’re talking about because this isn’t the normal path.

AND it turns out, as I found through this recent interaction, you basically HAVE to do it this way. Medicare has to have paid for the pump you’re using for it to be authorized to have the insulin covered as a component.

The one inconsistent thing is that I AM getting my reservoirs and insets covered through Medicare, through my existing DME supplier (Edgepark). My Dr had to send them some paperwork but it went without a hitch. So I’m not sure why insulin is so different, but probably something to do with the fact that it falls between two stools. From the DME supplier’s p.o.v. it’s a pharmaceutical, while pharm suppliers, whether online mail-order or brick-and-mortar, don’t do DME.

At any rate the bottom line turns out to be that I have to go ahead and get a new pump, something I’ve been avoiding b/c I have enough complication in my life without having to go through learning a new system and my Paradigm/Dexcom combo is dumb and simple enough and works fine for me. But like the cust svc lady said, “Well you can just go ahead and order a new one and not use it.o” I suppose, though there are complications to that that I won’t go into having already gone on so long about this…

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That’s incorrect. Medicare has never paid for my insulin pump, pump supplies or CGM supplies, other than insulin for my pump. There was a question about the date and who paid for the pump (used original date, not the free upgrade or 670G recall replacement).

I did make the point at the beginning with my Walgreens Pharmacy that I already had the pump and get everything else from the VA.

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Dr BB I understand what the agent said, but I feel fairly strongly that Medicare need not purchase the pump for insulin coverage. Besides, lets say this is now true (possible) That means insulin is part of the $35 / month medicare prescription provision. I think that makes it six one half dozen another except for the deductible?

According to this article, the $35 limit will apply for pumps starting in 2023.

“Some Medicare enrollees with diabetes take their insulin through a pump. The $35 maximum copay for insulin for that delivery system will begin on July 1, 2023.”

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I guess my take is somewhat overstated, but it was based on what the Medicare rep told me after demanding the date when I purchased my current pump. The problem being that she didn’t know sh** about it to begin with, had to bounce it up to a supervisor and then come back to me, so this is third hand from what they told her, or at least her interpretation of what they told her. (Remember the game of “telephone”? This is like that.)

My current status is that my endo talked to the Wallgreens Medicare manager, who on that basis okayed charging Medicare, but when I called in the refill, the cost to me was going to be something like $400 for 3 months’ supply. Which I guess is 20% of the list price (Fiasp), Medicare only covering 80%. I gather the remainder is somehow recoverable from my supplementary (United) but I don’t have $400 for the up front and I don’t know if I have to put in separately to get reimbursed, meaning I have to start a whole 'nother phone-hold-wait-explain-supervisor-agent-hold-wait-explain series with them, or does the pharmacy handle it somehow? And where does my Part B deductible figure into all this?

I’m sure these are all answerable questions given sufficient phone calling and explaining and listening to hold-music, but I’m SO out of gas for it right now. Fortunately I have enough insulin in my reserves that I can give ti a rest for awhile before heading back into the swamp, but MAN this whole thing is such a ridiculous TIME SINK. It just wears me down having to keep jumping through hoops over and over again, waiting on hold forever, waiting for this party to talk to that party to figure out what I’m supposed to do, answers coming back days later that only seem to lead to more questions/problems without resolving anything and agggggh.

This whole system is insane BY DESIGN. To quote Annie Hall, it’s a Kafkaesque experience.

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To get insulin covered under Medicare B there sre a lot of conditions still in 2023.

  1. Medicare defines need for a pump differently than a dotor does. They require proof that you are inulin dependent anc are unable to adequately manage your BG
  2. The pump must be Medicare-approved. Currently the only pumps approved under Part B are tubed.
  3. The pump must be used as submitted for FDA approval. That includes the insulins used during the clinical trials, which currently are only Humalog and Novolog. It takes a special appeal process to get an exception.
  4. A doctor must “monitor” a patient using a pump, and at no less than 6 month intervals, reauthorize the insulin. Mine does this by writing Rxs for 2-90 day supplies, which the pharmacy rounds down to a number of vials. If you change the doctor “managing” your treatment, it can delay approval of insulin ordered by the new doctor.

When I started uding a pump last April, I discovered that the Walmart where I’ve been getting Novolin for years didn’t know how to fill out the form that Medicare requires for coverage under Part B or insulin. I had to download the form and walk the pharmacist through the process of filling it out. Then I discovered that Walmart has got some kind of a special agreement where they collect the Part B copay even if it’s covered by your supplemental insurance, for you to be later reimbursed. Since then each of the reorders and new orders for my pump at this Walmart have been delayed or otherwise screwed up.

So I’m planning to move all of my prescriptions to a Walgreens where I have already inquired about their experience billing Medicare for insulin under Part B. The pharmacist told me that insulin for Part B comes from a different distributor and tskes z few days more to get?! That sounds like they’re cutting out some of the retail drug mansgement middle men.

Btw, The $35/mo copay under Part B doesn’t take effect until July 2023. Between now and then, depending on your other Rxs, supplements, doctor visits, and tests, it may be better to have tubed pump insulin covered under Part D. Part D in 2033 has no deductible for insulin while B has a deductible for everything it covers. In my case I’ll meet the Part B copay before I need more insulin

After my first fill, Walgreens entered the supplemental insurance in their system and I haven’t had to front he copay/deductible since. I don’t remember whether it was the local Walgreens or the Medicare group that set that up. The supplemental (Tricare) takes months to pay, so sometimes I get past due notices (not the case with Walgreens).

Walgreens hasn’t been able to get the submissions to Medicare correct and the claims keep getting rejected. Walgreens’ Medicare group hasn’t been concerned enough to do do anything other than resubmit rejected claims that again get rejected. I requested help from my Senator’s local office. Walgreens’ billing problem was fixed within about 2 weeks.

After 3+ years, FIASP is working as slow as Novolog. So, I’ll switch to getting Novolog from the the VA Pharmacy (FIASP not on VA formulary) and I’ll be leaving all the Medicare paperwork and hassles behind.

Hope your Medicare travails become easier going forward.

It has already pretty much started at most major pharmacies. In fact the FDA allows pharmacies to have the extra additional payments for medicare pump users back to August 2022. It is a bit of a mixed back at the moment, but overall it will be resolved by June of this year for everyone.

With the $35 Plan D cap on insulin what is the advantage of trying to get it through Plan B?

Plan B + Supplement should cover 100% and right now every penny counts.

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Its $400 for 3 months’ supply because its Plan B - 20% of the list price.
Plan D would cover it for 3 months at $105 or $35 per month.

@DrBB My Pharmacy has the information for Medicare and my supplemental plan. I’ve never been asked to pay it up front as they bill the insurance companies. Everything under Part B is covered 100% and I have small copays on Part D. It was $40 total for 3 months of insulin under Part D, last time there was no charge at all.

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