Thinking about Medicare

I just turned 60 and was thinking about getting closer to the dreaded Medicare options. My concern is that I’ve been a type one diabetic for 8 years and have only used pens. My understanding is that either Medicare doesn’t cover the pens or else the co-pay is very high. I have never used a pump and not sure if I want to try. Are syringes the only other option? They look very scary. Can you share your experience with Medicare?

I use a digital pen that takes cartridges. Cartridges are a little less expensive than pens. Being just 2 1/4 hours from the Canadian border, I drive up and buy all my insulin in Canada and then bring it into the US. Prices for the same insulin is about 90% less in Canada than in the US so box of 5 is in the $50 range or less depending on the current exchange rate. That allows me to take a very inexpensive Medicare Part D drug plan (wellCare), It was $14 per month for 2019 and is going up to $15.70 per month for 2020.

When combined with premiums, co-pays, donut holes, etc. that is by far the cheapest way to buy insulin if you are using pens. I buy $5200 at US list price for about $490 in Canada + $168 (12 months premium of $14) for a total insulin cost including insurance of $568 for the year. And I still get my tier 1 statin for $9/quarter so my entire drug costs are quite low.

There are many options depending on what you use and how much you need and the costs vary dramatically depending on your particular circumstances.

Medicare does cover pens but you are right, the insurance premiums + the co-pay are rather exorbitant. If you let us know a little more about your options, we may be help you out a little better.

Under current Medicare regulations for those who have Basic Medicare plus a Supplement, insulin pumps, the pump supplies, and the insulin for the pump are covered under Part B DME. Medicare pays 80% and my supplement pays the remaining 20% and thus I have no out of pocket cost. If you use syringes or pens, your insulin is covered under Part D prescription and is much more expensive with deductibles and copays and donut hole repercussions. My pharmacy plan has all insulin in Tier 3 so I would pay a percentage of the cost. Those who use a lot of insulin can find their bills quickly get high. Advantage plans can cover things differently so that would have to be researched plan by plan.

Medicare takes some work to figure out but my coverage is very good. So I don’t necessarily think that you should dread Medicare. However I don’t necessarily know whether Medicare will look the same in five years that it does now. Republicans would like to privatize Medicare and send all of us to Advantage plans. Democrats would like to move the whole country towards single payer. So the future of Medicare is very political.

When you get about a year away from your 65th birthday, you should start doing your homework to learn as much as possible. During the year prior to my Medicare enrollment, I changed my mind several times on the “best” plan for me and was glad that I continued to learn and research things.

This is a very good document created by JDRF:

https://www.jdrf.org/t1d-resources/living-with-t1d/insurance/medicare/

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This is helpful. I realize that a lot can change in the next few years with Medicare. I heard President Trump was going to work with Florida governor regarding purchasing insulin thru Canada. I’m in Illinois. Maybe more states will follow that plan. I’ve been happy using pens but the pump seems like the only affordable option with Medicare. I appreciate these responses. This site is so helpful!

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I used a ‘free’ service from an insurance broker to assist me and my wife in our Medicare A (Hospital), B (Medical), C (Medicare Advantage) and D (Prescription) applications. My ‘agent’ was extremely helpful in determining, when we should apply, what medicare part C plan we should be on, and what we needed for part D and in choosing an auxiliary insurance company to cover the 20% medicare does not pay. I will not provide the name of the company as that would be against my rules. I began researching at age 64 1/2, as I was born in 1952. Your dates for medicare will vary, depending on what year you were born. My agent returns yearly and we go through our medical history for the past year to determine if there is better plan for the next year.

It makes financial sense to use Insulin Infusion Pump instead of Insulin Injection Pens if one is qualified under Medicare Part B DME rules.

Medicare Part B DME and the Supplement Plan will pay for the cost of insulin, cartridges, syringes and infusion sets if the insulin-dependent diabetes’ C-Peptide levels are lower than 110% of lower limit of normal laboratory measurement (i.e. around 0.9 ng/dl or 0.3 nmol/l) with a concurrently obtained fasting glucose of less than 225 mg/dl. See the following link for the CMS rules:

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

Therefore, it makes sense to request C-Peptide with fasting glucose tests as early as possible before entering Medicare. If C-Peptide test result is greater than 1.0 ng/dl, you are not qualified under Part B DME rules. You may want to reduce your C-Peptide levels. Search this forum for solution.

NOTE: 0.9 ng/ml is the typical lower limit, hence, 110% of 0.9 is 1.0 ng/ml, which is the maximum allowable C-Peptide level meeting Medicare Part B criterion.