On Medicare and considering switching to CGM + pump... best device combination?


#1

I’m Type 2 and on Medicare and I’m considering switching to a pump because of the obscene costs of my Humalog and Levemir under my Medicare Part D coverage. My understanding is that Medicare will cover the cost of the Humalog (but not the Levemir) for those who use a pump and that’s my motivation.

As long as I’m considering a pump, it seems to make sense to me to dive into the CGM experience at the same time. It seems like a good combination of CGM + pump would be the best approach to helping me improve my control of my diabetes.

I’ve been browsing these forums and most of the topics are discussions among advanced users with extensive experience. However, for someone with little knowledge of these devices and their use, it’s more confusing than helpful. As I’ve said for many years, I don’t know what I don’t know.

So I’m looking for advice as to what the best combination of pump + CGM would be for right now but also with an eye to the future when these two types devices can talk to one another and (gasp) perhaps even our smartphones.

My other (related) question is what are the pitfalls of getting these devices and related supplies covered under Medicare?

Thanks for any help you’re able to provide.


#2

Have you ever asked your doctor for insulin? I get three or four bottles of Humalog when I go in for my appointments every 3 months. That saves me from the high co-pay associated with buying insulin at the pharmacy


#3

If you use Medicare coverage to get a Dexcom G5 they do not allow you to use a mobile device as a receiver. I don’t know how they will find out if someone was to use a mobile device but I’m not going to test the theory as I just got my G5 through Medicare.


#4

As someone with Type 2, your biggest hurdle to getting an insulin pump under Medicare will be the c-peptide requirement. Many people with Type 2 still produce too much insulin to meet the Medicare guideline that your c-peptide test must be 110% or less of the low lab value range.

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

For those who are on Basic Medicare with a Supplemental/Medigap plan, you are correct that insulin is covered under Medicare Part B at 80% with most supplemental plans picking up the remaining 20%. For me there is no out-of-pocket cost for insulin and the price of insulin does not go into the Part D donut hole calculations. For seniors on Advantage plans, it can be more difficult to get insulin covered under Part B. Some people have been able to do so, others have not been able to.

There is no doubt for me that because I am on Basic Medicare with a supplemental plan, that a pump is the most economical route. Everything related to the pump is covered under DME by Medicare at 80% with my supplement paying the balance. Those on Advantage plans often have to pay a percentage of the cost of their supplies as determined by their plan.

Because I am relatively new to Medicare, I am still using Dexcom G5 supplies purchased prior to Medicare and I am not yet bound by the ban on smartphone and pump use as receivers. Hopefully those nonsensical policies will change but right now the rule is that if you violate them, you must reimburse the price of supplies paid by Medicare and may be subject to criminal penalties.

Currently the only CGM covered by Medicare is the Dexcom G5. Although people with Type 2 often have a very difficult time getting CGM coverage with private insurance, Medicare does not exclude T2’s. You must meet these guidelines: https://www.dexcom.com/faq/medicare

So the most important things that you need to find out are 1) If you’ll medically qualify for a pump under Medicare guidelines and 2) How your Medicare plan covers DME.

If you have other questions, don’t hesitate to ask.


#5

If you are price sensitive, you might consider a Medtronic pump. I use Dex and Omnipod, but supplies are a bit more expensive because the entire pump (except the receiver) falls outside of the ‘durable medical device’ category - creating more out-of-pocket payment for the patient.


#6

Hi Laddie,

Thanks for the thoughtful and comprehensive response. However, it has brought up other questions. I took a look at my test history and don’t see anything that appears to be c-peptide even though I have had numerous lab tests due to a couple other medical conditions. Is that part of a test that returns numerous results (like the comprehensive metabolic panel or autohemogram/plate/diff)? I have about 10 lab tests scheduled in advance of my PCP Medicare Wellness Visit in late October and I can request specific tests if I need to.

I took a look at the Dexcom G5 and it seems like a good device. Like many other websites, you can’t find out how much it costs without registering to be contacted by a sales person. I do have Medicare and a great supplement plan so I’m not terribly concerned about the cost unless my PCP and I feel that it’s the best option for me and Medicare doesn’t agree. If that were the case, I’d seriously consider just outright buying the devices myself.

Right now I’m not sure I want to transition from MDI to CGM + pump. I’m using Humalog and Levemir and it’s costing me a lot even with a Medicare Part D policy. So, cost is an issue but it’s not the only issue. Another option I’m considering is switching to Novolin R and Novllin N. The cost is minimal and if I can obtain effective treatment for my diabetes that way, I’m okay with continuing with an MDI approach. The option of the always attached CGM + pump devices just seems to be an uncomfortable change for me.

I also looked at the Medtronic 670G (the only pump I’m aware of right now) and it seems like they’re trying to tell me that it’s a combination CGM + pump system. That’s cool but it also says it’s for Type 1 but does not mention Type 2. And again, no indication of what it might cost. It also only mentions basal but not bolus. Is that a whole different approach compared to the basal + bolus approach I’m currently using?

One little thing that I’d have to deal with is that Medicare says that in order to qualify for a CGM, one must have been using a regular meter at least four times a day for at least six months. I was instructed three times a day four years ago and it’s been working fine for me. .

Again, thanks so much for your insight and assistance. Remind me to buy you an adult beverage of your choice if we’re ever in the same area .


#7

Keep in touch with what you find out and decide. :grinning:


#8

The c-peptide test is a stand-alone test not usually included as part of a panel. You need this test if you want coverage by Medicare, whether T1D or T2D. The c-peptide test measures how much native insulin your body produces.


#9

Thanks much for that insight. I’ll request that it be added to the tests for my October appointment with my PCP.


#10

Hi Laddie, you appear very knowledgeable in The Medicare world of diabetes. Can you recommend some reading material? I’m turning 64 this month so I have a year to learn the best approach for my medicare coverage (supplementary or advantage).
Thanks