Problems with insurance

I am currently enrolled in a Medicare replacement program through Humana. I was put on an insulin pump and at that time I was told by Humana, my endo, and several pharmacists that my insulin costs would not count toward my coverage gap. Seems as Humana is now back tracking and counting this toward my coverage gap.

Has anyone else had this problem and if so, how was it resolved?? My insulin will now cost me $300 a month versus $40 that I was paying before I reached the gap. I cannot afford this and am in wonder what to do. Any suggestions would be helpful.

Good evening, Rusty. Insulin for use in an infusion pump is covered under part B of Medicare – not part D for prescription drugs. If you inject insulin (MDI) then it belongs in part D and counts toward the donut.

Having recently enrolled in Medicare, I am still arguing with Medicare to cover my current pump supplies and insulin as described above. My endo says this is very common and EVERYONE entering Medicare on a pump has to have the appropriate documentation filed with Medicare re: pump particulars and demonstrated medical necessity (C-peptide test results). All my documentation has been submitted, and I’m waiting for a new decision before appealing.


I agree with Gerry - insulin for the pump goes under Part B, not Part D. My guess is that your pharmacy is billing it wrong. When I got my pump last summer, it took quite a few phone calls to find someone that actually understood how to bill it correctly. Like Gerry said, your pharmacy needs a copy of the c-peptide.

That is what I thought but I cannot seem to get the idiots at Humana to understand that.

Thank you for your reply.

See comment above. Thanks for your reply Gerry. I was beginning to think I had passed over into a twilight zone and the rules had changed. Now I know that it is the insurance that is messing with me.

Your discussion needs to be with Medicare, not Humana!

I will be calling them first thing in the morning…Gonna ruin someones day…

Not all pharmacies are able to bill Medicare - it is possible that you are using a pharmacy that can’t do that. They should know how to do it right if they are a Medicare pharmacy. I had to change pharmacies to get pump insulin.

Check & see if your pharmacy participates in Medicare. Put your zip in and one of the categories on the left side towards the bottom is infusion pump insulin (or something to that effect). The ones with a “p” are participating.

This is WalMart. You would certainly think they could.

Showed nothing…Just my luck.

Just took a closer look at the link that you provided and there are some things on there that are not right. I put my zip code in and ticked the insulin pump box. It came back showing nothing so I expanded the search to 25 miles. Shows 3 places. The mileages are just a tad off though. Says the closest place is 17 miles away, in actuality it is about a mile as the crow flies. 2 of the places are oxygen supply places and the third is an optical company. I’ll send you my zip code in a pm and let you see for yourself…

I see what you mean Rusty. I know I had a hard time finding a place when I got my pump last summer. The pharmacy that I use doesn’t come up if I put the search up to 24 miles (they are about 15 miles) but if I put the zip code in where they are at, they come up in the search. I also changed my search to include test strips just to see if anything different came up.

I would call the pharmacy first & ask if they are billing straight to Medicare or thru your plan (it sounds as though they are billing thru your plan).

I got hopeful when I read your post Kelly, and then I found out that the nearest participating supplier is 100 miles from where I live. There are suppliers listed on the Medicare site, but they don’t handle insulin. I’m beginning to think that the suppliers get together and decided to just let the drug stores handle the insulin part of the pumps :frowning: With gasoline prices what they are today, I might not be saving a whole lot of $.

When I got my pump last summer, it took me a ton of phone calls to find someone that would sell insulin for the pump. I really did not like the idea of having it shipped because of problems with that.

I just filled a prescription for my insulin and paid $183.19 out of pocket. I was told by the clerk at the Pharmacy that Medicare doesn’t pay for insulin. I told her “next time I come in I will bring you a copy of the information from Medicare website”. :frowning:

That is crazy. I wish some of these people would learn how to do their jobs! Sometimes I think I need to put all the manuals in a very large suitcase and carry them all around with me so I have them when I needed them.

Mayumi, since you use a pump, Medicare does indeed cover your insulin. Please read the section in bold type at the website. Here is the link:

BMD - It is one thing to ‘know’ what Medicare says it covers and quite another to ‘find’ a provider that will bill Medicare directly.

Rusty, see my reply to Mayumi on the same topic. Talk to Medicare with the facts from their document.