Hallelujah! I just got my latest 90-day insulin refill via Humana, and thanks to the guvmint, my cost, still under Medicare, Part B, I presume, has dropped from the former 20% of $1,236 for four vials to $105. Your mileage may vary but it’s a big help for me, and I hope for other senior pump users insulin buyers as well.
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Same here. I was paying close to $600 every three months under Part B. (I use a lot of insulin) Last order I paid $105. Yea!! (This is under a Medicare Advantage Plan)
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I have regular Medicare and a pumper. I pay ZERO for my insulin used in my pump - under Part B. The prescription is required to be stated “used by an insulin pump.”
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It’s great to read that your insulin out of pocket cost has shrunk to a more reasonable amount! I think government has an important role to limit the greedy over-the-top instincts of corporations. Not obliterate the important role of the private economy; just to brings some balance with the needs of common citizens.
I think it’s important to note to more casual readers of this that many senior pump-using diabetics use traditional Medicare under Part B paired with a privately purchased Supplement plan to totally avoid any out of pocket ongoing insulin expense.
I only bring this up since this choice of coverage is time limited and once the window closes, the decision is irreversible. If you are nearing the all important age 65 time frame, pay attention and get educated! The short term appeal of a Medicare Advantage plan can easily become overwhelmed with serious long term health conditions.
For people who miss that chance or find that choice unaffordable, this moderating of insulin costs that @Tom_in_SC writes about is a breath of fresh air.
For what it’s worth, I moved to New Zealand a year ago. All prescription medications, including insulin pump supplies (which you get through the local pharmacy) are completely free. There’s one exception in my case, in that my jardiance (empagliflozin) does not qualify for public “funding” as I am a type 1, and it’s intended for type 2. That means I have to pay the full cost myself, which is $83/month. My insurance in the USA was paying about $800/month for the exact same medication.
There are downsides, for example Dexcom is still not “funded” so I have to pay out of pocket, about $1,200 NZD (about $700 USD) every 90 days which includes transmitters and sensors. From what I hear, the agency that determines what meds and devices are funded (PHARMAC) is currently accepting proposals from Dexcom, libre, etc to consider making them publicly funded devices.
The only other significant costs here are that GP (primary care) doctor visits cost $60 (free for all children under 14) but anything the GP refers you to, like endocrinologist, blood tests, radiology, etc is completely free. Also, unless I happen to have a consultation, every 90 days I have to pay my GP $17 to call in my prescriptions.
There are no premiums, deductibles, out of pocket maximums, etc. Everything is paid for via one chunk of payroll taxes (called PAYE), with tax rates almost the same as in the US… But with no expensive insurance premiums and line items like state tax, social security tax, etc coming out of each check we actually keep more out of every paycheck, and get universal cover.
Other downsides are that some meds are just not available here at all. PHARMAC has a pie of public funds to divide up each year in order to maximize public good. That means if you get a weird, rare disease there may not be any effective free meds available to you, or perhaps only older less effective meds are available. You can get private health insurance however, and this fills in those gaps, paying for non-pharmac funded meds, expanding cancer care, and giving you access to private doctors outside the public system which can reduce waiting.
Overall I think this system is much more fair. I had a friend here who suddenly had intense abdominal pain from a ruptured infected ovarian cyst and had to spend 3 weeks at hospital and have 2 surgeries. She never received a bill. Sadly, her inbusiness went insolvent as a result of the lost income. But at least she didn’t end up also with tens of thousands of dollars in medical debt also.
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“Medicare Advantage” often gives no advantage to a patient – it puts an insurance company between the patient and his/her/their healthcare program. And insurance companies may be inclined to make money by denying claims or limiting care to doctors you might not otherwise choose. I have a number of friends whose care is being delayed because of the added hoops they have to jump through to satisfy their insurance company’s Advantage plan.
And, the government’s mandated reduction of the cost of insulin is also available through regular Medicare.
Just saying …
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Details on Medicare insulin costs.
For those not on Medicare, there are cash pay discounts.
I get 3 vials of Novolog or Tresiba for $99 using this offer.
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Congratulations! I’m so happy for ya!!!
I am so happy that I have traditional Medicare + Supplement → $0 for insulin for the pump! The only (minor) downside, is that Medicare requires quarterly visits to your PC or Endocrinologist. I like my endo and her PA, so the visits are pleasant and short.
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Im in traditional Medicare too, and HAD been getting my pump insulin at $0 cost through Part B for several years - until last August 2023, when the new $35 prescription rule went into effect. It really messed me up. Now, for a 3-month supply, it’s going through my Part D prescription plan, and I’m charged $105!
I asked several Medicare reps if I can still get it through my Part B - they ALWAYS answer their stock answer of “ Medicare covers 80%, and your supplement should pick up the 20%.”
Finally, my endo office has told me that they can’t file insulin for pumps under Part B - only Part D!
Are you gettng your insulin through Part B for DME?
I just got pump supplies and insulin in Dec. along with G7 sensors and all went through Part B. I think you medical supplier/pharmacy is confused about who to charge. The new insulin rule does not effect DME rules. From Medicare website:
Insulin
Medicare Part B (Medical Insurance)
covers insulin if you use an insulin pump that’s covered under Part B’s durable medical equipment benefit. Part B doesn’t cover insulin pens or insulin-related supplies like:
- Syringes
- Needles
- Alcohol swabs
- Gauze
Part D
covers these:
- Injectable insulin that isn’t used with a traditional insulin pump
- Insulin used with a disposable insulin pump
- Certain medical supplies used to inject insulin, like syringes, gauze, and alcohol swabs
- Insulin that’s inhaled
Your costs in Original Medicare
- The cost of a one-month supply of each Part D- and Part B-covered insulin is capped at $35, and you don’t have to pay a deductible for insulin. If you get a 3-month supply of insulin, your costs can’t be more than $35 for each month’s supply of each covered insulin. This means you’ll generally pay no more than $105 for a 3-month supply of covered insulin.
- Under Part D, the $35 cap applies to everyone who takes insulin, even if you get Extra Help.
- If you have Part B and Medicare supplement Insurance (Medigap) that pays your Part B coinsurance, your plan should cover the $35/month (or less) cost for each covered insulin.
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That all makes sense- and it confirms what I already knew. But WHY can’t Medicare reos tell me that? And as far as my pharmacy, they insisted that it was Medicare who refused to cover it through Part B,because of the quantity- m prescription is for 15 vials for 3 month supply. My pharmacy was getting defensive and refusing de because of all my questions, probably because they weren’t doing it properly!
I guess I’ll try another pharmacy. Make be they can do Part B correctly!
Insulin under Part B is for tubed pumps only. Omnipod is Part D if on plan formulary.
I have only used tubed pumps, so didn’t think about tubeless. Well, that is a big plus to change to tubed if you are on Medicare.
In your December insulin Part B order, did you pay something for it?
No, my Medigap ins. picks up to 20% that Medicare doesn’t cover.
That’s the way it went for me up until July '23, when they said that new law went into effect. That started my irritating conversation with Medicare!
According to the Omnipod website, Omnipod is covered under Plan D (Am I Covered? | Omnipod). Thus, it is not considered a DME under Medicare Part B and hence insulin would not be covered under Plan B.
I dont have a pod - I have a Medtronic pump, a Medicare approved pump, so I SHOULD be getting my pump insulin under Part B for DME.
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@jgbar1950 I am sorry to hear you are still struggling with getting the Kroger pharmacy submit the claims for your insulin correctly. Lets start with some information to help you understand what is going wrong and then I’ve got some suggestions on how to get it fixed.
- Medicare Part B has always only covered 80% of approved claims after the (tiny) deductible is met.
- The remaining 20% and deductible might then be paid by a Medigap plan (aka Medicare supplemental insurance aka Medicare Part F, G, K, L, M or N). If you also have a Medicaid plan it might provide coverage. Anything not covered was paid by you.
- Medicare doc explaining the change to the $35/month insulin copay for Part B.
Since you were paying $0 for insulin for your pump before July 2023 you have (had?) some coverage that was paying the 20%. Check with that plan to see if they cover the Part B $35 copay for insulin. Also check they still accept claims from Kroger pharmacies.
If the plan covers the $35 copays call Kroger’s Medicare info phone number. and ask them
- Can Kroger still bill Medicare Part B?
- Can Kroger still bill the remaining amounts to a Medigap plan?
- Optional: Can Kroger bill Part B for a 90 day supply if the doctor has satisficed all the necessary requirements?
If the answers are yes ask the person if they can look at your account and fix whatever problems are preventing billing your medigap plan and using the proper coding for a 90 day supply of insulin.
My personal experience is the people who work the pharmacy cash register are so undertrained and underpaid they’ll say all sorts of crazy things when trying to be helpful. If the Kroger pharmacy phone reps can’t help the next time you go to the store for the refill, give the cashier a chance to change it to Part B and bill your medigap plan. If they fail compassionately ask them to contact someone who can fix the problem.
Let us know how it goes.