Not for the fainthearted - Part B/Medicare

Here’s the story from my experience with CCS Medical: they stink and need to be forced to do what they were contracted to do with Medicare (CMS).

Rule #1: I make no insulin!

I don’t state Rule #1 to be critical of anyone who makes insulin, but as an important fact when dealing with profit based insurance companies or medical equipment suppliers. It IS my experience that insurance and DME suppliers tend to treat me as though I make insulin. They also tend to want to amend my doctors orders to better suit their profit driven business model. While never confirmed or denied by CCS Medical, I found it to be the case.

You will need to contact CMS to get CCS to give you what you need, what your doctor has ordered. CMS contact information can be found on the internet by district and then by specialty/medicare part. there will be phone and email contact information listed. Contact them and explain your problem to the point. Do not expect a reply from CMS, but you hopefully will be contacted by CCS Medical cheerfully compleating the order as written by your doctor.

My CCS Medical oddessy began when I began losing my vision after over 30 years of being T1. Now being disabled, I went on Medicare. At the time Medicare did not cover the OmniPod that I was using at that time, but they did cover the Medronics Minimed G630 under part B and the insulin to fill it. Medrtonics farmed my case out to CCS Medical who I was told handles all of their Medicare clients. Medicare likes to move in blocks of 90 day supply. This is faulty in that all months of the year do not contain 30 days. Look at your calendar. Any 3 consecutive months do not contain 90 days. Also when using a pump does it always last 3 days? Do you sweat one off, knock it off or have failure of any kind making you replace it ahead of the 3 day guideline? Whatever the reason, it happens. My doctor has written prescriptions/orders for a few extra to cover these unforeseen events. I cannot go without insulin. See Rule #1. CCS Medical would not send me the extra supplies, claiming that Medicare doesn’t allow it. They told me to have my doctor to call their compliance department, which she did. She was frustrated by them when they told her Medicare doesn’t cover that amount of insulin. But, CCS Medical DOES NOT provide insulin, only a delivery system. I can’t go without introducing insulin to my body. Rationing is NOT the answer. That lead me to contacting a consumer reporter. See this link: https://www.nbcnewyork.com/news/local/diabetic-man-worried-about-running-out-of-equipment_new-york/1990136/](https://www.nbcnewyork.com/news/local/diabetic-man-worried-about-running-out-of-equipment_new-york/1990136/)

I post that to show that you do have recourse to get what your doctor ordered even under Medicare and CCS Medical will try to use misinformation to maintain their profit margin. I’m sorry this was sooo long but I hate when organizations try to take advantage of the misinformed. Arm yourself with fact. You don’t have a lot of time as a T1 to debate treatment with a non doctor. Your very life depends on you being an advocate for yourself!!

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I though I would add to this thread about some further things I learned trying to get insulin for a pump covered under Part B Medicare.

Note: I have original Medicare and a good BS (that’s Blue Shield …) supplement. Despite the fact that my prescriptions have always been written as “Insulin for use in insulin pump …” it has always been processed under Part D. Based on what I have learned on this forum, I knew that was wrong … and based on what I have learned from @Dave44, I thought I knew exactly what I needed.

Trip 1 to the pharmacy: my brand new prescription for insulin had once again been processed under Part D. (This is at the second largest pharmacy chain in the US …). I ask to speak to the pharmacist and, good news, she knows that this should be processed as Part B and says she will take care of it. Hallelujah!

Trip 2: The first part B request failed and they have a paper form for me to fill out that asks for the information that @Dave44 said I would need: Pump manufacturer, model, serial number, purchase date, and check boxes for “continuous” and “subcutaneous”. Note: it also had “J1817” prefilled out of the form. I later learned that J1817 is the HCPCS (Healthcare Common Procedures Coding System) code for “Insulin for insulin pump use.”
Curiously, they also asked for my height and weight …
So, that gets FAXED (yes, FAXED) to CMS and I’m instructed to come back the next day.

Visit 3: The previous form was rejected because there were “missing codes”. I don’t honestly know whether there should have been additional HCPCS codes, they were missing appropriate ICD-10 (International Classification of Diseases), or some other type of code. Because this is all done by FAX, the pharmacist had to copy everything onto a second form, add the missing codes (whatever they were) … and check the “Resubmission” box … and FAX it again. Come back later this afternoon …

Visit 4: THAT version was REJECTED. Why? Because the pharmacist had failed to copy my height and weight from the original form. I have no idea why CMS cares that I’m short (5’9”) and dumpy (158 lbs) before they will approve insulin … but they clearly do.

Visit 5: They have insulin ready!!! But the CoPay is higher than it should be. Why? Blue Shield rejected their part …

I have no idea why … and probably can’t find out until I can look at various EOBs online and get a refund.

Anyone wonder why we spend a greater fraction of our GDP on medical care than anyone else on the planet and collectively have substandard care to show for it?

Lest I sound ungrateful: let me repeat: I am VERRRRY lucky to have excellent healthcare AND insurance!!! It just sometimes takes more effort to get the coverage for which I am supposedly eligible.

I hope this tale will help those of you who get a paper form in order to get a prescription approved by CMS.

Best of luck,

John

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From above: Rule #1 I make no insulin. I restate Rule #1 here because I, too, was amazed that Medicare (CMS) wanted to know my height and weight. Your H and W would be used to calculate your Body Mass Index. But my BMI has nothing to do with my T1. I was thin when I was diagnosed. CMS is often used as a "standard practice model) by many health insurance companies. It points up that not even CMS has a clear understanding of what T1 is and how I came to be one. They might as well ask if I smoke or if I prefer blondes, brunettes or redheads? I thought it might be CMS gathering statistical data, but no, all of that should be in my doctors report.

Looking for solutions again. Because of this forum I finally got my pump and cgm supplies. You all are the best!

Now I am still fighting to get insulin. Is there anyone out there who knows of a competent pharmacy in Dallas Texas that can submit a claim for insulin under part B?
The first pharmacy I used finally had it go through 3 months ago, but for some reason they are now very unhappy with the process. I was told I didn’t know what I was talking about regarding part B ( has to be part D)…sigh::: that the last time I was there, the pharmacy tech spent a lot of time figuring out the system and finally got it to work. Now this same pharmacy wanted to let me know that this is just way too much work and are holding up my order because the previous copay has not yet reached their desk ( i offered to pay it and advised that once they get the copay the could reimburse me.) “They aren’t set up for that”. I prefer not to have to beg for insulin if I don’t have to, so am reaching out to fellow pumpers, over age 65 with regular medicare and supplement, for

a pharmacy recommendation that understands… anywhere in or near Dallas.

I will tell you my story and hopefully this is relatable. As you may know by now, I’m on medicare at age 56 because I became vision impaired. Before this I was using the OmniPod and getting my insulin for it via prescription according to my then employer’s healthcare insurance plan. When I transitioned to medicare, OmniPod was not covered under Part B and became very expensive. The insulin rapidly accelerated me to the “donut hole”. I had to switch to a pump that medicare recognizes as a covered pump and for me that was the Medronic MiniMed 630G. Medicare covers this under Durable Medical coverage (PartB). Medicare’s guidelines state that a covered part B pump shall have the insulin for it also covered by part B at no cost to you the end user. For the pharmacy that provides the insulin under Part B, it ends up being a financial loss. Medicare pays the pharmacy below even the wholesale proce of the insulin. A small pharmacy can’t make up the loss in other medicare business because of their smaller sales volume. A large national chain pharmacy can.

My pard D is through SilverScripts and is a partner with CVS/Caremark. If there is a CVS pharmacy in your area, that’s where I would go. The pharmacy I deal with for insulin is Wahlgreens, but I don’t think they are west of the Mississippi . Medicare accepting providers can lose their contract with Medicare or be fined/sanctioned if they don’t fill these scripts and follow the guideline procedures. It’s a little more work for the pharmacist because they have to call part B medicare and respond to the questions about you. YMMV. I hope this helps a little! Good luck!

I just Googled it. You’ve go many CVS pharmacies in Dallas!

Thanks for the suggestion- I just got back from Walgreens. The counter staff didn’t understand. I asked them to talk to pharmacist and he seemed to get it. Fingers crossed they are working on it.