Switching from private to medicare + supplements

Ok all you old Medicare geezers, I’m now officially one of you and I don’t like it!

Specifically I’m going nuts trying to get all my prescriptions changed over from my employer-based coverage to my shiny new SilverScripts PDP plan. I made sure to get everything I could filled before the change took effect (April 1) in order to avoid any gaps in medication, but I find myself in a loop that even Kafka might have admired as a model of sheer bureaucratic futility.

Problem 1: both my old insurance and new PDP use CVS Caremark. There is no way to update existing Caremark account to the new coverage; you have to create a new account using a different email address. Ok fine, done. So how do you get your prescriptions into the new account? Apparently you have to have your Dr issue all new ones. Leading to Problem 2.

Problem 2: I use Patient Gateway to manage my visit appts., medications, payments and all that. It sits on the very widespread EPIC medical database. I can enter my new insurance info for Medicare (Part A & B) and my Medicare Supplement plan (UnitedHealthCare) . But when I go to enter my PDP (Aetna Silverscripts) the screen says “pending” and then the info just disappears. So I call my Dr (Endo) prescription line. They refer me to the network-wide patient registration office, which says they can’t add a PDP—they can do the other stuff, but not that. Why??? Who knows—and they refer me back to the Endo’s office, which sends me to Prescriptions, which sends me to Registration, which… you get the picture.

And then there’s…

Problem 3: Dexcom. CGM is DME now, not pharmaceutical. Will they be covered? Medicare says I need to prove that I have paid for and “own the monitor device.” Meaning what??? There is no “device,” just the transmitter and sensors. Wait, do they mean the quasi-mythological “receiver” that Dexcom never sold me and most people don’t use, and back when you had to have for Medicare but now I think it’s ok to just use your phone like 90% of us do? The guy couldn’t say. He did say I’d need to present some kind of documentary evidence showing that I had paid for the thing in the past. Like my old Caremark has records of my payments for transmitters and sensors, so is that good enough? And present to whom, exactly? Well, the pharmacy, the guy says. So I call Walgreens. They have no idea what I’m talking about.

Problem 4: Pump Supplies. This one—I think—might be straightforward. Same nonsense about proving I’ve bought the stuff in the past, but I use Edgepark, and they seemed to think there wouldn’t be any problem. Just enter my new Medicare A/B info into their system (done) and they should be able to check it through and fulfill it.

Question 1: Has anyone else done the Caremark prescription transfer thing, and how did you do it? Just have your dr submit the whole list of scripts using the new PDP info (if I can ever figure out how to get it into the system)? Or something else?

Question 2: Has anyone else gone through the Dexcom changeover from private/pharmaceutical to Medicare B/DME? What documentation did you have to scrape up and whom did you submit it to?

Finally: thank GOD I’ve got a pretty decent zombie-apocalypse stash built up, particularly of the Dexcom stuff. But I’m starting to wonder if it’s going to hold me up until I can get all these knots untangled. Uggh.

3 Likes

I was on Medicare for quite a few years before getting on Dexcom but I took the easy route as I am at Joslin Boston, as I believe you are as well. Joslin Boston has a person dedicated to dealing with Dexcom filings and any/all of its issues, Joslin filed all the required notes, and documentation with Dexcom/Medicare part B and it was a totally painless option. Back then, Medicare patients received all supplies directly from Dexcom, but when Dexcom switched to third-party vendors and no longer dealt directly with the patient for supplies, once again I went to the Dexcom guru at Joslin and they made the transition seamless. The only thing I needed to do was to specify which vendor I wanted to get my supplies through and they gave me a list of a 1/2 dozen or so to choose from. I went with ccs and they have been awesome.

2 Likes

I was for a long time, and they were the ones who first started me on Lantus/Novolog MDI, then to a pump, and then got me on to Dexcom (a Dexcom 4). But then I changed to my spouse’s health plan a while back and Joslin was no longer in network. They were great about stuff like this, which is one cause for regret, but alas financial considerations drove us to the other plan.

I actually first started getting Dex. supplies thru Walgreens b/c the Walgreens was right inside the clinic and they had everything in stock, plus even the pharmacy staff included several T1’s. So I’ve kept using them (Walgreens) even after the switch of plans.

1 Like

Now that you are on Medicare is it maybe time to look to switch back to Joslin? My PartB BCBS Bronze Medex plan covers my Dexcom and Joslin 100%, I am covered worldwide so no in network issues, no copays, no deductibles, and it is really quite cheap at about $650 per quarter.

2 Likes

I suppose I might do that–I have UnitedHealthCare and the plan covers specialists without deductible or network restrictions. But I’m actually pretty happy with the endo I ended up with after the change. Also her diabetes assistant, who I FINALLY found it is the Medicare coordinator and the right person to help me through this maze.

2 Likes

That is always the best answer. Let the experts that deal with Medicare/Dexcom all day long deal with it and do all that frustrating heavy lifting. Can you do it yourself? Sure, but you can also probably rebuild your automobile engine if your life depended on it but that does not mean you should even attempt it unless you are really into that kind of challenge.

Maybe call the companies involved and have them deal with a lot of it? I had a really easy time of it. I had BC/BS through my husbands past employer,went on Medicare and the BC/BS plan automatically changed to a gap type insurance instead. But it was “new” and got assigned all new numbers and in fact, the new insurance can’t look at the records of the old insurance.

I called my doctors office and gave them the new information and they handled when they submitted insulin and Omnipod scripts to the new insurance. Which was still Optum Rx as the supplier, but now would also be the ones sending pods (Medicare says they are pharmacy). I called Omnipod to tell them I was switching to Medicare as they have on their site they would help the transition to make sure they got covered. I called OptumRx and gave them the new insurance information. Then I called Dexcom and they gave me ADS as being a good supplier for me for the Dexcom and they contacted them and sent them the info. ADS was wonderful, contacted me and took care of all of anything needed.

So I called the Doctors office, Omnipod, OptumRX and Dexcom.

Part of the reader/phone issue with Dexcom was the phone was never approved as the sole reader for Dexcom? The only reason you are allowed the phone as a reader is it’s secondary and the reader is the primary reader. Part of that is the phone won’t always work as in examples the updates messing it up and in my case the new iphone is not compatible either, so it doesn’t always work right. So they want you to have the reader.

It’s easiest to have the endo’s people handle this. There are different standard protocols for IIS and CGM prescriptions for existing and new users and they change over time. They earn the changes, and the learning curve is spread over many patients. They have an incentive and many opportunities to refine their system for doing this to reduce the time and effort required.

Using the same insurance company or pharmacy, is irrelevant as far as a new Medicare Part D plan is concerned. You get a new policy, and you are treated like a new subscriber with different rules , the big one being automatic acceptance.

Once you have Part D coverage, it’s a one year policy whose coverage and cost changes each year. If the policy type remains the same from the same company, and you “renew” by doing nothing during the Oct-Dec period, you accept whatever the changes are. If you change to a different Part D plan from the SAME provider, you will get a new, different policy and subscriber number.

Medicare, not the Part D provider, sets all the rules for what is required for a therapy to be covered. All the provider can do is determine which pay tier a prescribed item should be in and your co-pay.

If you change to a new Part D insurance carrier, they are required to accept prescriptions that were previously covered under Medicare Part D, with two exceptions. 1)They may have a different FDA approved-as therapeutically-equivalent substitute in their formulary and its tiers of coverage. eq Atovastatin may be a tier 1 replacement for Pravastatin, and/or both drugs may be in different tiers. . 2) A former Part D item my be re-categorized by Medicare as covered under Part B or vice versa.

Once you are covered by Medicare, every year you will need to get new prescriptions. Unless there is a change in what has been prescribed that Medicare B covers, there is no other paperwork required.

1 Like

I am on Medicare and also use the Dexcom G6. If your regular Walgreens pharmacy gives you a hassle with getting Dexcom supplies, switch to a Walgreens Community Health Pharmacy. I have had nothing but excuses and problems with the regular neighborhood Walgreens pharmacies both in Wisconsin and in Florida, but the minute I changed to the Walgreens Community Health pharmacy in Madison, Wisconsin, my G6 supplies were sent directly to my door. I did need to get a new prescription sent to them from my Endo’s office. When I went to Florida in the winter, my Wisconsin store gave me the address of the nearest Walgreens Community Health pharmacy in Florida. I get an e-mail from them each month that it is time to get my G6 supplies, and once again I arrange to have them sent directly to my door. Both pharmacies ALWAYS deliver the supplies by the very next day. Please consider checking out Walgreens Community Health pharmacies in your area. They ARE different from the regular Walgreens, and they have done an excellent job filling my Dexcom sensor and transmitter needs.

7 Likes

When I changed from my employer’s plan to Medicare, using Caremark, I just called Caremark (using the info provided by the new account) and told them that I was doing the change. The rep I talked to was able to look up all my old-account Rx’s and transferred them over. Everything went smooth as silk. I did have my old Rx numbers, name of drug, dosage, frequency, etc.

My DexCom and t:slim supplies are with Byram and other than them hassling me mercilessly if I am late in refilling, that has also gone pretty well.

Which brings me to insulin. I have had major hassles getting my insulin via Medicare Part B. I have used Walgreens, CVS, and now Kroger. I order the refill at least a week before it is due for refill, and the pharmacy doesn’t do a thing with it until a week after the refill date, despite my calling to nag every other day.

Regarding Problem 3:

Medicare will not fund CGM supplies unless you have and use a non-smartphone “receiver.”

I personally prefer using the Dexcom receiver over my smartphone, but I suspect most people are just the opposite. Since the G6 transmitter is able to update both the Dexcom receiver and a smart device, I suppose some people carry both all the time. In any case, you basically need to prove you have the Dexcom receiver and claim you use it.

2 Likes

It’s possible that policy is expired…I started on Medicare this year and have never been required to prove I own a Dexcom receiver. (I do by the way and use both the receiver and iPhone depending on what I’m doing). I’ve been ordering G6 sensors and transmitters from Edwards Medical.

1 Like

I did have a long convo with the DME who’s now going to be doing Dexcom stuff for me, and they absolutely did require it whether or not it’s still on the books with Medicare proper, so what the heck–they went ahead and sent me one at no additional cost. Who am I to object to free D stuff. Well, “free” more or less anyway…

1 Like

That’s what happened when I changed over so I have it for back-up.

That is not true. Medicare requires you to possess a Dexcom receiver but does not require you to use it. Every time Medicare upgrades to a new system, they send me a receiver as required by Medicare but the receiver goes straight into a drawer and never gets used as for the past few years, Medicare now also allows you to use a smartphone instead of the Dexcom receiver as long as you also possess a Dexcom receiver.

3 Likes

I also had CVS under my private insurance and switched to CVS under Medicare. Yes you do have to create a separate account. To update the prescriptions I just used the Rx request feature “start delivery by mail” I think it’s called. You just type in the name of the drug and submit it and caremark contacts the doctor.

I made the transition from private insurance to medicare part B for my Medtronic pump and it was pretty straightforward. A few wrinkles with medicare though:

  1. You have to see your endo every 90 days and have him/her forward a summary of the visit to the supplier.
  2. I get my supplies through Medtronic and according to them Medicare will only allow you to replace your supplies when you have 10 days worth left. They ask how often do you change your sets and how many do you have left. Since it takes them at least a week to fill and ship the order that cuts it pretty close, So when you order, if they ask, tell them you only have 10 days of supplies left.
4 Likes