New to Medicare. Help please!

#1

I am going on Medicare in September and am very nervous about prescription costs. I have had a great insurance plan which included free insulin and test strips. I currently use a One Touch Ultra and test 4-6 times per day. I have LADA, and do MDI. Any help people can provide on choosing supplemental plans would be greatly appreciated.

#2

Each state runs something called the State Health Insurance Assistance Program (SHIP). This program is free of charge and provides help in choosing a Medicare Supplemental Plan. I used them when I went on Medicare and found their advice dependable. Unlike people selling various insurance options, this advice comes with no conflict of interest.

Here’s the link to the Medicare site that can help you identify this resource in your state.

I ended up selecting the standard Medicare plan (not the Advantage plan) with a Supplement plan. Many people choose plans F or G for their supplemental coverage. Both F & G provide the same coverage except that plan G does not cover the Medicare Part B deductible like plan F does. But plan G’s premium reduction compared to plan F is more than enough to cover the out-of-pocket Part B deductible cost.

I use a prescription plan benefit that I earned from a former employer to cover my medication needs. If you don’t have coverage like this, then you’ll need to select coverage from Medicare Part D plan offers.

The deadline to make your choice is a flexible one; you have several months before and after your 65th birthday to get this done. Good luck!

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#3

You can opt in to a new Medicare supplemental D plan every year, so it is a little early to decide what you may want or need at this time. So much can happen between now and next September that what is good for you now may not work starting September.

Plans vary by state and by what you are looking to accomplish.

You talk about using One Touch Ultra and 4-6 test strips per day. Medicare fully covers a CGM including all supplies and that does not require supplemental plan. Your supplemental plan would be for your medications, especially insulin if you will not be pumping and obtaining insulin under plan B.

Your best plan for medications will depend on what medications you take and how much those medications cost. Each Insurance company has a calculator to help you put in your estimates so that they can give you a quote. Past few years I was on one of the many AARP supplemental plans as they were the best deal for me but when I started to buy my Insulin in Canada, reducing my insulin cost by 90% from US list price, WellCare at $14 per month was a much better deal for me.

Next year, you may reduce your insulin requirements by eating a lower carb diet, for example, and that could affect which is best plan for you, or insulin costs may drop, or you may shop them in Canada.

There is a lot of “help” available online, however, much of the help is useless as it is generic and not particular to your requirements. I found the best was to do a search online based on my criteria and then contact the insurers to review their plan. It sounds like a horrendous nightmare but after you look at 1 or 2 plans, you quickly know what to look for and what to ask and what to tell the insurance company so you can select the best plan.

Make a few notes because once you have gone through this once, it is easy to forget next year the steps you went through to find the best deal and then need to start your process from scratch again. With a few notes, following years become a breeze.

#4

Worst com to worst, if something goes wrong during your transition, you can always get test strips off the shelf, and crappy, old man insulin over the counter, without a prescription, at Walmart pharmacy ($25/bottle - long term NPH and short term R). I believe this is Walmart’s nationally negotiated deal.

#5

CJ114 - Medicare only pays 80% of the covered charges for a CGM and supplies. A supplementary (or Medigap) plan can pick up up the additional 20%.

If you have a particular Medicare Advantage plan this may be different.

#6

CalderonGD:

Yes - Sorry about that. Looks like it is my MEDEX covering the other 20%

#7

That’s cool. Just wanting to be sure.

#8

If you have Basic Medicare with a Supplement (Medigap), it is much cheaper to use a pump because your insulin is also covered under DME Part B. My pump, pump supplies, and insulin are all covered 80% by Medicare with the remaining 20% being covered by my supplement plan. Thus no out of pocket cost. Same with my Dexcom CGM. If I were MDI, I would be purchasing 2 kinds of insulin through my Part D plan, paying Tier 3 copays and hitting the donut hole. If you go with an Advantage plan, your answers for these things are different, but chances are you pay 20% of the cost of your CGM, pump, etc. Please note that if you do not select a Supplemental plan during your initial benefit period, they are allowed to use underwriting in the future to deny you coverage or charge you higher premiums. If you stay with MDI an Advantage plan with it’s cheaper premiums will probably serve you well. But understand that you can always switch from Basic Medicare and a Supplement to an Advantage plan, but with a preexisting condition you are very limited in the ability to switch from an Advantage plan to a Supplement.

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#9

Nice summary, @Laddie. The point you make here is an important one. I just wish our access to health care in this country did not build in traps like this. I’m happy, however, with my health care access that Medicare + Supplement gives me.

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#10

Thanks to everyone. I think I definitely need to talk to someone at the State Assistance Program. Laddie, that was really helpful to know you can switch from Basic Medicare and a Supplement to an Advantage plan, but with a preexisting condition you are very limited in the ability to switch from an Advantage plan to a Supplement. With several pre-existing conditions in addition to diabetes, I am very nervous about making the wrong choice. Seems like switching from MDI to pump may be the way to go. And I just learned that the FreeStyle libre is covered by Medicare as well as the Dexcom. I did search online and under Plan D I was told my prescription costs would be $8,000 a year!

#11

I have been a SHIP counselor for Medicare and please contact the SHIP office for your state. They are an excellent resource. Laddie summarized it best but they will help you with your individual needs. Especially with a search for Part D. I would be surprised if the best plan would cost you $8000 per year.

#12

I did not see any mention of a plan costing $8000 per year. Under my Part D my prescription costs for insulin are also about $8000 but that has nothing to do with the cost of the plan. My plan costs me $14 per month but don’t use it for insulin because I can buy $8000 of insulin at US MSRP for about USD 800 in Canada. Buying in Canada is way less than my copays are in the US under any Part D plan I have found.

#13

Sorry misunderstood. I was lucky this and my plan insulin is about the same as Canada. But have used Canada before and it works pretty well.

Don’t forget to check new plans every year as they change constantly. I am on my 4th Part D plan in 4 years.

Janelle

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#14

Blockquote

Very interesting and informative. Thanks.

#15

Sounds like things are changing in the donut hole.

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#16

Thank goodness for that. I hit the donut hole on Feb 12. I’ll be in catastrophic coverage by late March, sigh

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#17

Few extra points to add to some of the comments:

  1. With Medicare you have to “qualify” to be on an insulin pump. If you are type 1, you should have no problems. If you are an insulin dependent type 2, then there may be some problems. To qualify you have to have little to no insulin production. (Not all Type 2 diabetics on insulin are without their own insulin production- some are, some aren’t)

  2. Medicare does pay for insulin through Medicare Part B if you “qualify” for the insulin pump (as above). This can be helpful but it seems that not every knows about it. Some pharmacies may be challenged at first to figure out how to do it.

  3. For those who have fallen in the coverage gap, look to the manufacturer and see if you qualify for patient assistance. Many of the insulin manufacturers have patient assistance programs that Medicare patients can apply once they reach the coverage gap. The one downside is that, if you qualify financially, you may have to spend a certain amount on medications before the assistance program can assist (one company I think it’s $1,000). The good news is that everything that you spend or have spent on your prescriptions from January 1 to whatever time all count. (Copays, deductibles, etc) so, once you reach the coverage gap, you should already have made headway to that amount.

These programs can be very generous in their financial qualifying limits. Lilly (Humalog/Basaglar) I believe is the most generous. Last year then totally revamped their assistance program so they were getting help to more people and less fell through the cracks.

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#18

I was right behind you. I hit the donut hole a week later than you, also in February.

#19

It appears to me that the benefits described in the article closing the gap (donut hole), paying 25% is misleading. If the list price of an insulin is $400, then 25% is $100. BUT, if the list price of an insulin is $1200, then 25% is $300.

My point is the list price is just raised in order to defeat the savings touted for the gap closure.

The price of insulin (going up all the time) also affects the 5% we will be paying in the catastrophic stage.

I could be wrong but this is how it seems to me.

#20

How does a type 2 qualify or prove their body’s insulin production or lack thereof? Is there a lab test and if so, how is it measured if one is using insulin injections?

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