OK here is what I did…any over 65’s with experience in Medicare please tell me if I screwed this up.
Signed up for a Medicare Advantage plan before I turned 65. Started in on the plan, everything seemed great. Today I hit the “coverage gap” for pharmacy meaning my co pays went through the roof for Omnipod. (15 pods Dash co pay was $47 and is now $208). For reasons unknown to me, the coverage gap does not appear to increase my insulin co-pay, still at $35.
I still have the option of dropping this Advantage and getting a Medicare Supplement and a Part D pharmacy plan…but I might have to wait until open enrollment (not sure).
My questions are:
Does the pharmacy coverage gap still happen with all of the Medicare supplement + Part D plans? My understanding is that with Medicare supplement plan the insulin and Omnipod will be covered under Part B…does that mean no coverage gap for them?.
Speaking as a 62 year old medicare lurker… The $35 is just the whack-a-mole insulin cost thing; no more than $35/month for insulin:
The co-pay for Part C (I assume) is irrelevant, except that you have to pay it “up front”, i.e. at the start of the year. You care about the OOPMax (same as ACA):
My cost for each Dash pod is $52.941; so $794 for 15 of the little buggers. But then my (ACA) OOPMax is somewhere around $6500 this year; I don’t pay more than that for anything that the ACA covers. It’s much more complicated with Medicare (parts A-Z) as the gohealth article explains. One relevant paragraph is:
If your Medicare Advantage plan includes Part D (prescription drug) coverage, the cost of your medications will not go towards your out-of-pocket maximum. Neither will uncovered services your plan doesn’t cover.
Oops. Then read down to the stuff in the “Medicare Part D Out-of-Pocket Maximums” section.
My approach (with the ACA, but the ACA is much much simpler than Medicare) is to estimate, fairly accurately, my total expenditure in the year then back calculate the total cost of the insurance plan. It’s necessary to have a fairly accurate guesstimate of full price to get this right, but that can normally be obtained from prior year prescriptions or by directly calling an insurer and asking what the full price is (or at least the “co-pay” and dividing by the percentage.)
Someone else needs to comment about using, or not using Part D when the retail cost is of the order of between $7,000 and $10,000 (pump+CGM).
I found another word problem from Hell to explain the Part D coverage gap and how the OOP costs are figured. Looks like my best course is to keep spending pharmacy co pays at the higher rate and see if I hit $7,050 OOP at which point the co pay drops to 5%. Medicare Part D Cost Sharing Chart (ncoa.org)
Advantage plans are tricky, for a lot of people, they are a cheaper route to get care. But they still want to come out ahead money wise so they have control over costs in other ways. Switching back to Medicare and part D, I think you have to pay more for pharmacy when you do after you have been in an advantage plan? Someone else might know more about that. Personally if you can afford it regular Medicare with a gap insurance supplies a lot of benefits in choices and coverage. But it costs more for most people. So your budget plays a part.
But Omnipod falls under Pharmacy benefits and not Part B under regular Medicare. I pay $40 for a 3 month supply as my Gap insurance picks up the difference, even the donut hole at the beginning of the year (it’s through my husbands past employer).
My Omnipod amd Dexcom total uninsured costs are about $250,000 per year. Of course I am in a panic about finding a plan to pay for these. None of the Part D plans I have looked at pay for the Dexcom. Upon inquiry, the Part D insurers tall me that a CGM is a Durable (DME). Medicare will pay 80%, leaving me with a $50K/year cost.
I am trying to find a Medigap plan, but every time I search for Medigap or Medicare supplemental, Google takes me to Advantage plans which I want to avoid. Ever wonder why Medicare Advantage is so heavily advertised? That’s where the insurers make their money. They don’t like writing Medigap plans because they lose money on every one of them. But they are required to offer them.
Insulin Pumps and CGM’s are covered under Part B except for Omnipod.
Omnipod is definitely covered under Part D, Pharmacy, because the pods are disposable. It doesn’t make sense as Dexcom sensors are disposable but that is how Insulet got coverage for them. Omnipod is not even trying to attempt to change that. Maybe with their new Loop system of the Omnipod 5 since I believe it will be linked with a Dexcom it might be changed? I have both, an Omnipod and a Dexcom, I’ve been covered under Medicare for over a year now and I’ve talked to Medicare specifically about Omnipod coverage. Insulin for the Omnipod is also covered under Part D and not B because the Omnipod itself being Part D. Whether some slip through the cracks,I have no idea. And Advantage plans can be different of what they cover and how.
I have Medicare and a gap policy. I don’t pay anything for Dexcom. I pay $40 for a 3 month supply of pods and $40 for a 3 month supply of insulin. I also now pay $100 for a 3 month supply of Afrezza.
Make sure you don’t go without drug coverage.They calculate a penalty based on the months without coverage and add that to your bill for every month thereafter.
I don’t understand this. Have you called Insulet and Dexcom to see what their cash-pay (no insurance) monthly out of pocked cost would be? I think it’s around $300 for pods and something similar (within a factor of 2) for the sensors. It’s difficult to see how you’d have to pay more than about $10k, nevermind $250k.
If I recall correctly, pods can be considered disposable supplies for the PDM which can be covered as durable medical equipment, so the pods can be covered under part B, just like the insulin. This is the same reasoning as for Dexcom sensors and transmitters, which can be the disposable supplies for the durable Dexcom receiver. That said, you may be able to get the disposable supplies through the pharmacy channel, which may be either less or more expensive depending on your particular insurance plan.
The Med Advantage I am on right now covers pods as Part D, pharmacy. So far I’ve been unable to find a Medigap plan that covers the Part D coverage gap co pay. It seems like the plans that cover this are grandfathered in and no new Medigap plans the last few years have covered this. So I am going to power through the donut hole and see how the pod + insulin coverage is a few months down the line after I exceed the donut hole.
The way Insulet worked round this was that with the Dash pods the PDM is a freebie (and, yes, they do give them out with great abandon - IRC I now have three or four).
It was discussed here a while back; the Eros pods were unavailable under Medicare because Insulet was unable to get approval for the whole thing (I suspect someentity made a large payment to ensure this was so, but that’s just me).
So Insulet went, I guess, “If you can’t beat them join them.” The Dash pods are disposable, they do require a device, but it is given away free. The analogy that put the CMS and their bosses supporters in a bind was that blood glucose test strips are not DME of themselves even though they invariably require a special purpose meter; the meter is free. (They are DME, or at least they were, if used with a DME pump or CGM, but not if used with MDI, as I understand the situation as of four or five years ago.)
This, I assume, is why my private insurance company decided that the Omnipod was no longer DME; the insurance company was getting reamed by the PBM, going the prescription route, while it can hardly be said to fix the problem, at least helped a few bucks.
Dexcom chose a different boat, perhaps the one with the holes in it. I believe they are now in the position where they have to start giving the receiver away for free - everything else is prescription and, let’s face it, how many people use the receiver? At this point the receiver preserves the Gx’s status as DME, but the lock on their chastity belt seems to be missing, and the value of having it does too if people on Medicare are allowed to use it.
That should happen automatically; it is the Omnipod that communicates with the G6. The spatula in the endocrine surgery might be the activation of the G6; I’m not sure how that works. On the other hand Insulet have been doing this for a while now and I’m betting (hoping) they don’t want to go back to DME; a single DME taints the whole batch.