As usual, I’m dealing with the annual Medicare Advantage Plan search and I’m confused. I’ll keep at it, of course, but I’d bet many of you here already know what I want to ask.
I use Novolog in a Tandem tslim pump. I get a 90 day supply by mail order from my Humana Gold Plus HMO plan. Since this past July, thx to the govmint, it’s cheaper than before, which is good.
But in reviewing my current plan on medicare.gov, it seems as if Medicare is telling me my Humana plan in 2025 will no longer cover my insulin.
Usually, this is because generic websites always include insulin as if it’s covered by Part D and if you use it in a pump it isn’t covered by Part D, it’s covered by Part B, and the generic software doesn’t know that. Generic phone answerers don’t either, most of the time.
So what’s the truth? Did Medicare stop covering insulin used in pumps by Part B in 2025 or am I just seeing the usual inaccurate website information? Medicare.gov is saying my plan in 2025 will cost me a bit over $1,000 for my insulin and that clearly doesn’t reflect any government cost reductions since last July (e.g., no more than $35/month, etc).
I’ll call Humana of course but I’d like any info anyone here also knows.
If you have an Advantage Plan, that company is administering your Part B benefits. Thus it is likely that you are bound by their formulary. I am with Original Medicare and have never had formulary restrictions on my choice of insulin. But that doesn’t mean I won’t get Aspart instead of Novolog or Lispro instead of Humalog.
On Facebook many seniors have complained that they are not finding Novolog in their Part D and/or Advantage Plan formularies for 2025.
I’m one of those seniors too, who have been told I cant get my preferred insulin for 2025. I have a Medigap and Part D Rx plan and they dropped Fiasp off the formulary for 2025. I received a letter through the mail telling me that it was no longer covered in 2025. My Part D insurance is with Well care and the provide is Express Scripts. When I called the pharmacy plan thy said I could fill out a Request for Medical Necessity.
I have had much better results with Fiasp than Novalog or Humalog. I talked to my PA and Endo and they said it was easy to justify with the medical necessity request because of my history.
Since others have complained about this as Laddie has pointed out, I think Big Pharma is pushing back on the $35/month insulin restriction. If you want it for $35/month you have only one option. In my case it Novalog.
I am concerned about what the cost might be. I use 3 vials per month and with a list price of ~$300/per vial that will be close to $900/month. Now Virginia has caped insulin price for all T1D’s at $35/month.
We will have to just wait and see how this will play out.
Medicare Advantage plans are Medicare Part C. Someone with Medicare Part C is not covered by Medicare Parts A, B and sometimes D. Therefore the policies in Part B that apply to pumps do not apply.
In your case, evaluating Medicare Advantage plans, you need to refer to the plan documents to see if insulin for a pump is covered separately from the prescription drug benefits.
I did a search for 2025 Humana Gold Plus HMO plans in South Carolina. Holy smokes that’s a complicated plan. Doesn’t make it good or bad, just makes me appreciate what I have. Depending where you live in SC or if you opt for the Diabetes SNP version there are 4 formularies that might apply to the plan you are looking at. Novolog is listed as a Tier 3 drug in all four formularies. I don’t see any rapid acting insulins in Tier 1 or 2 to get you under the $35 cap. I didn’t look to see if any of the plans offer alternative coverages for pump insulin. I will if you can narrow down which plan you are looking at with a zip code near you and if you are looking at the SNP or not the SNP plan.
I hope this helps you find a plan that works for you for a reasonable cost.
@TEH4PWR the copay is capped at $35 for some people. Novo, Lily and Sanofi still get paid full price for the drugs.
That was nice of them at least. I only found out mine dropped it when I decided to check whether I needed to switch coverage during open enrollment and saw that my estimated cost for 2025 under my current plan was going to go up over $10,000.
I have AARP/United Health Care for my Supplement (aka medigap) and SilverScripts for Rx. The latter has dropped Fiasp coverage (and Jardiance btw, which I also use) for 2025. I see that a lot of other plans have as well. But because I use Fiasp in a pump I’m getting it as DME/Part B, which is covered 85% by medicare and the remaining 15% by UHC. I did some checking and calling around, and AFAICT both entities are entirely agnostic about what kind of insulin you use when it’s DME. More precisely, Medicare doesn’t care–there’s no question of a formulary because it’s not being covered as a drug but a pump component—and UHC told me they don’t care either–as long as Medicare authorizes it, they pay their share too.
So this year I’m just not putting it into my drug prescriptions list at all. Which does make me a bit queasy. Pump failures can happen. But the Rx plans that do cover it are $$$. I’ve always had scrips for Lantus & Fiasp pens as emergency backup. Gonna make sure to get those filled before Jan 1.
