Our retirement benefit has remained mostly the same but changed the Pharmacy Benefits Manger for part D to Silver Scripts (CVS) One of the changes is that they don’t handle Humalog, but Novolog, fine by me as Humalog tends to be less effective on day 3.
My question is that insulin for a pump is suppose to be under Part B DME supplies. What is the advantage to having it paid by Part B as opposed to Part D?
How do i get it charged to Part B? CVS seems clueless about Part B.
One plus with the change is that Afrezza is in the formulary, I was wanting to try it for those stubborn highs.
@CarlosLuis Most direct answer regarding Part B vs D: Using myself as an example with retired military Tricare for Life (TFL) coverage, what Medicare doesn’t cover regarding prescriptions is pretty much covered by TFL; example I pick-up my insulin pens, that I use in my pump, at a military pharmacy for free, or with a variable co-pay via a network pharmacy or mail-order as long as the insulin is in the military formulary (some require Pre-Approval or Medical Necessity, like Afrezza was just added with PA/MN). So I only have Medicare A and B, not D. Others with secondary coverage (not Part D) probably have similar coverage. I don’t think it’s possible to get insulin changed from Part D to B; Part B coverage is what Medicare says it is. My understanding is Medicare currently says the DME (Durable Medical Equipment) portion covers “some” pumps and the insulin for the “some” pumps as long as it doesn’t come in pens or cartridges for pens. Otherwise, insulin is only covered by secondary insurance or Medicare Part C or D. Medicare also says Part B does not cover syringes, alcohol swabs, inhaled insulin, or bandages. So people like me that use insulin pens, instead of vials, as the source of insulin need secondary insurance, a Part D plan, or a Part C plan that extends coverage to pens/cartridges as an insulin source.
When thinking of Medicare, I can’t help but think of the MASH episode where I think it’s LTC Blake asking Radar if he understand the Army’s system. Radar’s response, “Oh no sir, that just slows down the paperwork!” And yes, I’m dating myself again, but a classic is a classic!
I have to admit MediCare is still something of a mystery to me; I have my exam for entry in March so I may know more afterwards!
My understanding is that there is no choice; if you use a Part B pump all supplies relating to that pump and the pump itself are Part B. E.g:
The pump
The catheters
The insulin (so you possibly no longer get the new “$35/month” insulin, but that isn’t clear).
However on a Part B pump you are not allowed to use pens; you have to use vials of insulin to be covered.
So there is no advantage; you are just getting some extra insulin for some reason. Of course that might be an advantage; it might be better to buy the insulin on Part D for some medical condition completely unrelated to the pump insulin. It’s somewhat underhand; you have a pump and you aren’t getting insulin for it? I always used to get my insulin pens from Turkey, much cheaper there and, at the time, it wasn’t banned.
If you have a disposable pump everything is on Part D. No choice.
Here’s the long story:
I didn’t read that. Well not all of it, quite a few bits maybe. Some maybe true some maybe not. I based what I said on the CMS (pre, ATM, Dr Oz) web site.
I use Tandem tSlim which qualifies as DME ergo the pump itself and any insulin or supplies required to use it are covered under Part B. OTOH Omnipod does not qualify as DME and is therefore covered, kit and caboodle, under Part D only.
As mentioned DME is an acronym for durable medical equipment.What are the criteria for qualifying as DME? It is an old rule originally developed to cover wheelchairs, crutches, Oxygen equipment etc. Basically, it’s stuff you don’t consume or throw away after use. I don’t toss tSlim in the trash after one set so it’s durable. Omnipod is a single use device so it doesn’t qualify.
Now you may ask why then is Dexcom CGM covered under Part B? Obviously not durable. Well the answer has to do with that Dexcom receiver lurking somewhere in a junk drawer in your house. Dexcom got FDA approval for the Dexcom Receiver (which you do NOT throw away, right?) as DME and the CGM itself is just a “supply item” required to use it. In fact, when I started Medicare, a rep from my DME supplier called me and made me dig the receiver up and give him the serial number. I also had to verbally attest that I use the receiver at least one day out of every calendar quarter. My government has made a liar out of me!
I think Omnipod could have gone the same route. Just conjecture here, but they may have decided to get the thing to market without the extra regulatory headaches of a DME approval. Probably a savvy decision as this device has great market strength in the young, active demographic. They decided to forego seniors.
Is it better (cheaper) to use Part B over Part D for covered insulin? Well, no, its $35 month just like Part D. But if you enrolled in a Medicare Supplement Plan when you first started Medicare it is covered 100%. A significant savings. Also Part B has no “formulary” that changes every year. It just covers whatever insulin the doctor orders.
So how do you get the insulin prescription for your shiny new FDA approved DME pump processed through Part B because you have a supplement and want to save $420 a year?
The directions for use written by your doctor on the pump insulin prescription order must state that it is for use through a pump, something like “Up to 40 units per day via pump injection continuous”. The pharmacist is supposed to see this and know to put it through Part B. But they don’t always notice. I’ve been on Medicare for a year and CVS processed my pump insulin through Part D twice already. This resulted in an overcharge that I did not detect right away. I was able to get the money refunded both times. It was not straightforward. Deal directly with the actual pharmacist and they will find a way to get you refunded, eventually. Now I ALWAYS ask which part of Medicare the insulin was processed through before paying. And then I check the receipt.