I just started on a pump under Medicare. I pay each month for Part B coverage, plus a Blue Cross Medicare Supplement plan that covers the 20% Part B copay after an annual deductable.
For everything to date that is covered under Medicare B, the provider bills Medicare, and Medicare sends the Supplement provider a statement to tell them what their payment part is. Often Blue Cross pays the balance before I get the monthly statement from Medicare.
The pharmacy that is providing the first insulin prescription for the pump (Walmart) says that I must pay the copay out of pocket, and I will get a letter in a month to take to Walmart for a refund.
Is this normal?
Medicare Part B pays for insulin
There is a simple answer to getting the insuling paid in full by Medicare. The MD must write a prescription that has the following info:
1- the insulin is used in a pump
2-the insulin is medically necessary
3-the specific number of units used daily(md can create a number that is greater than what you use)
4-may need MD to send in data or charts notes, not always needed
The pharmacy needs to request the info on the Rx to get it paid for by Medicare. All too often the pharmacies think it won’t be paid for by Medicare because it’s a drug, but it fall under the part B coverage.
I know what is required to get Medicare to pay for IIS insulin. It was submitted to Medicare and approved for use with a pump.
My question was about the need to pay the retailer the copay and get reimbursed later instead of Medicare sending the bill for co-payment to the Secondary insurer.
While I have never dealt with Walmart, that is not the way that it works at CVS. I pay zero out of pocket. When they DO ask for a copay, I know that they have messed up and tried to process it as a normal prescription. I believe that others on this forum have waged that battle as well.
In my experience, only a handful of folks working at a commercial pharmacy understand how to process a Medicare Part B prescription, because it happens so infrequently.
I may be off base in terms of Walmart, but I think that they tried to push it through the Part D pipe …
Not sure you understand my message. To get insulin paid for with a pump it needs to be bill by the retailer directly to Medicare part b. Medicare will not reimburse you for your out of pocket expenses if it’s not billed directly to Medicare part B when you pick it up. Some retailers don’t understand this, as was noted in the previous message, the retailer may need some guidance. When I first started Medicare CVS did not know they could bill it directly if used in a pump with the RX written just as I listed, this is required when billing to part b, and without this info in the Rx it will not be paid by Medicare.
If the insulin is not billed to part b it’s just like any other drug, you need a plan to pay for the drugs at the ins co-pay, and Medicare will not reimburse for that cost.
Hope that helps.
My diabetes educator who is who has Type 1 and wears a pump told me that in Illinois pharmacies may work differently than in other states.
I checked that the pharmacy billed Medicare the entire amount and got the copay information from them. The number they showed me was list price,
From the copay amount I can tell that what Medicare pays them for Novolog is $178/vial or about half of list price. It seems wasteful of Medicare dollars that they can’t specify white label Novo Nordisk Insulin Aspart or Lilly Insulin Lipro and pay half as much.
I wonder how long it will take for my “refund” letter from the Medicare supplement insurer.