My C-Peptide. < 0.1
Normal lab range: .8 - 5.2
Anti-body positive, but was done about 25 years ago, and don’t have details.
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Lots of really good answers have already been posted. My transition from my company’s private insurance to Medicare was mostly uneventful. I do agree you really want Medicare supplemental insurance (I went with a Plan G). No problem at all getting approval for Dexcom CGM.
Initially and then from time to time, Medicare really requires “doctor’s notes” and will not approve payment if your doctor’s office is tardy in sending those in. Obviously this means you need to be seeing your Endo or similar doctor regularly.
Overall, with the supplemental insurance, I have seen no problems being a T1D on Medicare.
We have a supplemental added to Medicare that we don’t have to pay anything for Medicare or copays, but it’s through his past employer. We just have to pay for $40 for 3 month supply of scripts. It worked out great for us. I’ve heard some horror stories about the advantage plans of what they decide to cover and change so you have to be careful as some have said, they sound great up front
Dexcom is free…but my pump is Omnipod and because of some weird quirk with Omnipod, pods are classed as pharmacy instead of DME. So I pay $40 for 3 months worth no matter how many I need. (DME would be free for me) I think that possibly any insulin used with a Omnipod pod falls under pharmacy too? I use pens to fill mine so it definitely is under pharmacy. No biggy because that is my preference and $80 every 3 months for both isn’t a problem for me.
I had absolutely no problem when switching to Medicare and them covering everything. I didn’t have to do any extra tests as I had a C-peptide when I was diagnosed. I’m not sure about this next part, but from what I understand with Medicare you are supposed to see a doctor every 3 months on the dot for pump scripts to be covered??? Maybe some one else can clarify that? Because the Omnipod is covered under pharmacy OptumRX has said that it’s not a problem. I will find out because my endo just changed my appointment to another 3 months away as she is out “indefinitely” right now.
But I had everything before I switched and it all was just switched over to Medicare and the supplemental.
Here’s how the timing of doctor’s appointments and Medicare script coverage works. For pump supplies and the insulin to fill that pump, a qualified Medicare vendor will verify before shipping that you have indeed been seen by a doctor within the last 90 days. For CGM supplies, I believe the rule is six months. If you don’t meet the 90 day or six month rule, the vendor will refuse to ship or they risk not getting paid. They usually want chart notes of your visit from your doctor.
So yeah, if you use a pump, you’ll need to see your doctor every 90 days and if you use a CGM without a pump then you can let six months lapse between doctor visits. But you don’t have to manage the calendar exactly; if you go 100 or 110 days between visits, your supply will still work.
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As a type 1 who went on Medicare last year I think straight red white and blue Medicare is way better than an advantage plan. As long as you can afford a supplement to pay 20% part b costs. When on a pump insulin is considered durable medical equipment and goes through part b costing me nothing. Whereas when In the donut hole of part d insulin can start costing hundreds of dollars even if it is a preferred brand. Aside from my $140. Supplement premium and the part b deductible. I have had NO out of pocket costs on Medicare for Dexcom pumps insulin or md appts
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Caps on monthly out of pocket insulin costs only work with Part D. I’m on an insulin pump, so costs aren’t capped. However, my supplement pays my 20% share.
If you don’t qualify for pump and CGM based on C-peptide, check or ask about qualifying based on antibody tests.