New to Medicare. Help please!

#21

Hey @MOOBM – if I end up having to be on insulin as a type 2, Medicare should cover it yes? My father does the pens and whatever else. He’s on Blue Cross Blue Shield thru my moms work though. I am assuming my doctor or nurse practitioner would make it the case to tell Medicare/whatever insurance that yes this patient does need insulin/insulin pump/whatever.

To my understanding, most if not all insulin companies have programs made so you get a “card” to save on your insulin at your pharmacy of choice.

Also, seconding @Babs5

#22

Doctor’s (endo) notes

#23

I heard about donut holes when I signed up for Medicare. It sounded scary. It appears I’ve never fallen into it during the last ~3 years. whew!

#24

Medicare has specific rules related to results of C-peptide test,
in addition to doctors notes of being medically necessary.

#25

C-peptide lab test.

From Medicare: “CMS has determined that fasting C-peptide levels will only be considered valid when a concurrently obtained fasting glucose is ≤ 225 mg/dL. Insulinopenia is defined as a fasting C-peptide level that is less than or equal to 110 percent of the lower limit of normal of the laboratory’s measurement method. Alternatively, for patients with renal insufficiency and a creatinine clearance (actual or calculated from age, gender, weight and serum creatinine) ≤ 50 ml/minute, insulinopenia is defined as a fasting C-peptide level that is less than or equal to 200 percent of the lower limit of normal of the laboratory’s measurement method. Levels only need to be documented once in the medical records.”

https://www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?NCAId=109

2 Likes
#26

@Babs5 and @dogdemon
To qualify for an insulin pump through Medicare you have to:

  1. Be on multiple daily injections (I believe at least three) of insulin
  2. Be testing your blood sugars an average of 4 times a day for 60 days prior to
    obtaining (I have always heard that it had to be 4 times a day exactly everyday but
    Medicare’s document on the matter says “average” of 4 times a day) the insulin
    pump. (You should have to provide actual glucose logs)
  3. You have to have seen a diabetic nurse at some point
  4. You have to have a fasting glucose and C-Peptide lab test (have to be same draw)
    Also, preferably, the lab needs to notate on the results that you are fasting for the test but, if they don’t, the doctor can make the notation on the labs himself and sign it.
  • The fasting glucose has to be less than 225. I would recommend that before doing the test checking your glucose on your home meter and, if it is less than 210, you should be “safe”. (Home meters don’t have the same accuracy as a venous blood draw so you don’t want to be 225 on your home glucose meter because it may actually be higher.) (Ideally, in terms of general health you obviously you want it lower than that but those are the cut off numbers for the testing). The C-Peptide has to be less than or equal to 110% of normal reference value. If you have poor kidney function (a GFR less than 50) then it has to be less than or equal to 200% of the normal reference range. (Which I believe translates to the level can’t be greater than 110% of the lower limit of the reference range- or 200% in people with diminished kidney function).

If your blood sugars are at the higher end when you do the lab and your C-Peptide is borderline qualifying. Try the test again with lower fasting glucose it will make the C-Peptide lower.

Your doctor will have to send in chart notes stating with all the above information and it should notated that you have seen the diabetic nurse (if you have…If you haven’t- you need to for coverage). Should also notate things like if you have variability in your glucose and/or your A1c is greater than 7.0%.

To maintain coverage with the insulin pump you HAVE to see your provider EVERY 90 days. Do not be late. Medicare is a law so when they say within 90 days from the previous appointment they mean within 90 days, not 91 days.

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#27

@dogdemon
Yes, if you end up being on insulin and you have a prescription drug program, Medicare Part D will cover your insulin. Insulin can be covered under Part B (Medical benefit) as durable medical if you are on an insulin pump and have “qualified” through Medicare. (Part B is also what covers the glucose testing supplies). The biggest difference between the Part B and Part D is the coverage gap (or donut hole). Part D has the coverage gap and Part B does not. In my experience, most diabetics, particularly type 2, on insulin will fall into the coverage gap at some point. Type 1s (not on an insulin pump) may “escape” the coverage gap if their insulin requirements are low and they aren’t on a lot of other medications. It seems those that require very large amounts of insulin can hit the coverage gap within the first quarter, most of the type 2s hit it by the summer or early fall.

Just to be clear, it isn’t just the use of insulin that can push you into that. There are other excellent medications for Type 2 diabetes that can also push you into the coverage gap (so you aren’t necessarily “escape” the coverage gap by avoiding insulin).

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#28

I’m not aware of any nurse I’ve seen being diabetic. Maybe, but not sure.

Sorry, just joking, sort of.

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#29

Well if you had met my wife you would have seen a diabetic nurse. That’s because she is a nurse and she is a diabetic. So there you go

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#30

:rofl::rofl: @dave44

#31

Technically, it is what is required for Medicare (and Kaiser) patients in particular. I think other plans may also require it but not as steadfastly. That being said, you don’t actually have to send proof because it’s possible that “proof” doesn’t exist anymore. (For example, if you saw a diabetic nurse 30 years ago when you were first diagnosed and you aren’t still a patient of the original doctor that diagnosed you then that “proof” may have been lost to time and record purging.)

#32

I forgot to add this is only with certain insulin pumps. Medicare just recently approved Omnipods but Omnipods can only be processed as a prescription benefit, not medical. This is extremely recent so I’m not sure all the ins and outs of it but I don’t believe it requires any of the documentation that I mentioned before. The biggest downsides to Omnipod being prescriptions only are:

  1. The insulin would not be covered under Part B like it is with other insulin pumps that are covered as a medical benefit.
  2. The cost of the Omnipods themselves are going to count towards your prescription benefit coverage so you will fall into the coverage gap even faster.
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#33

Loved your post. That was funny.

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#34

Did you reach catastrophic in March as expected?

It appears to me that they use list price to get you INTO the gap as soon as possible, then use out of pocket price to delay moving you into catastrophic. They don’t use the same dollar types to calculate for each stage.

#35

I like donuts, but I despise the donut HOLE.

Being diabetic, I can’t have donuts but the government makes me eat the holes?

1 Like
#36

Lol, no. I’m working with my endo to get patient assistance from Novo Nordisk. My 3 month copay would have been $775 and I just can’t.

#37

I just put in my refill for ONE month’s supply on both of my insulins. Expecting it to cost several hundred dollars. I will post again when they advise me of the amount I have to pay.

I refilled ALL of my other scripts earlier this week in an attempt to get closer to the exit of the donut hole. Did not make it so I am STILL in the hole since February and will have to pay donut hole fees on my insulins.

My endo gives me samples when he has them available.

#38

That is about my copay for a ONE month supply.

Maybe I should go on a pump so I can get my insulin through Part B instead of Part D. I may make inquiry into that as a possibility.