Humalog/Novolog and Medicare

[Northeast Agent]

Last night I was running a Part D for a new client who uses Humalog. I emailed her for more information as she didn't say if she gets it as a solution, cartridge or a pen injector. She replied back she doesn't pay for it as she has an insulin pump, and since the insulin goes into it, Medicare pays for it (she has a MS).

Page 16 of The Medicare.gov guide, "Medicare Coverage of Diabetes Supplies & Services" talks about Medicare drug plans, but it's confusing.

I'm looking at the Medicare.gov site, and it's possible it falls under DME.

Now my dilemma MAY be I already have another existing client with a pump using Novolog (solution). He's been my MS client for a year and has been paying for Novolog using Part D. He did get a new pump earlier this year paid for by Medicare - don't you think that either his doctor or the pharmacist would have mentioned this?

 

[somarco]

Not impossible.

You pay 100% for insulin (unless used with an insulin pump, then you pay 20% of the Medicare-approved amount, and the Part B deductible applies). You pay 100% for syringes and needles, unless you have Medicare prescription drug coverage (Part D).
Insulin Coverage

The challenge is finding a pharmacy that is approved to file Part B claims. Ask your client who she/he uses.

Endo SHOULD know about Part B + pump + insulin. They have to document the DME before Medicare will pay for it. And only certain models are appoved as DME.

A GP or internist may not know these things.

Another CMS resource
https://www.cms.gov/Outreach-and-Ed...-MLN/MLNMattersArticles/downloads/SE18011.pdf

and this from a private site

Diabetes Supplies, What Medicare Covers


and this ...
Medicare Part B covers blood sugar monitors, blood sugar test strips, lancet devices, lancets, and glucose control solutions for beneficiaries with diabetes, whether or not they use insulin, but the amount covered varies.

Beneficiaries with diabetes who use insulin may be able to get up to 300 test strips and 300 lancets every three months. Beneficiaries with diabetes who don't use insulin may be able to get up to 100 test strips and 100 lancets every three months. If your doctor says it is medically necessary, you can get additional quantities of testing supplies. Additional documentation is required.
Medicare | ADA


and this . . .
Making the Switch to Medicare with Diabetes

 

[Northeast Agent]

somarco said:

The challenge is finding a pharmacy that is approved to file Part B claims. Ask your client who she/he uses.

He and the wife are "pharmacy hoppers." I've had to remind them several times about using preferred pharmacies. Why they don't use just one is beyond me. But he seems to enjoy running to Costco, WalMart, etc on his days off. Maybe a "honey-do" list.

Endo SHOULD know about Part B + pump + insulin. They have to document the DME before Medicare will pay for it. And only certain models are appoved as DME.

A GP or internist may not know these things.

His wife said it took awhile, but Medicare paid for the pump, as his last one was old. I'm going to stop by there tomorrow as she said he'll be home and ask if the doctor mentioned anything about the insulin cost.

I'm going to make some calls next week to the local pharmacies and find out who is approved to file Part B claims. Then I'll also read the links you sent, so I'm better educated about Medicare & diabetes.

 

[TwoCents]

The challenge is finding a pharmacy that is approved to file Part B claims. Ask your client who she/he uses.

This 100%!

 

[somarco]

@Northeast Agent if you want to get involved you should join or view diabetic forums. In particular those that use CGM's.

Medicare pays for certain brands and models.

Medicare to Cover Therapeutic CGM, Sets Criteria

https://endocrinenews.endocrine.org/new-rules-medicare-now-extends-coverage-of-cgms/

Medicare Coding for Dexcom | Dexcom Provider

Dexcom has lobbied Medicare to get their pumps approved. Quite a few competitors are left out.

Pharmacy shoppers need to get their act together if they want insulin and supplies paid by Part B. The cost to them for doing things their own way are very high.

 

[kgmom219]

Last night I was running a Part D for a new client who uses Humalog. I emailed her for more information as she didn't say if she gets it as a solution, cartridge or a pen injector. She replied back she doesn't pay for it as she has an insulin pump, and since the insulin goes into it, Medicare pays for it (she has a MS).

Page 16 of The Medicare.gov guide, "Medicare Coverage of Diabetes Supplies & Services" talks about Medicare drug plans, but it's confusing.

I'm looking at the Medicare.gov site, and it's possible it falls under DME.

Now my dilemma MAY be I already have another existing client with a pump using Novolog (solution). He's been my MS client for a year and has been paying for Novolog using Part D. He did get a new pump earlier this year paid for by Medicare - don't you think that either his doctor or the pharmacist would have mentioned this?

NO. Never assume the docs or pharmacists understand insurance. They went to school for 12 years for other stuff.

If (and only if) they use a pump, these drugs are covered under Part B. I send my clients to the Walgreens Specialty Pharmacy, only because I haven't gotten any complaints. They also provide the testing supplies, so it makes it easier.

 

[somarco]

Walgreens Specialty Pharmacy

WOW! Never heard of this. You are a wealth of information.

Looked at the site very quickly. Did not see anything about insulin and Part B.

Not doubting you of course, must have missed it

Specialty Pharmacy | Walgreens.com

 

[kgmom219]

WOW! Never heard of this. You are a wealth of information.

Looked at the site very quickly. Did not see anything about insulin and Part B.

Not doubting you of course, must have missed it

Specialty Pharmacy | Walgreens.com

Nah. I just know who to ask.

One of the BFF's is Type 1, on a pump and very active in the Juvenile Diabetes community. Had a client dealing with this last summer and asked her to post it out to her group for some insight on the fast acting insulin costs for a pump when on Medicare and this was the response. Then I checked it out.

As an aside, this is a huge frigging problem for both Medicare recipients and those under 65, whether they are on group or individual plans. The pumps (which of course get their R&D funding from Big Pharma) can only use "fast acting insulin" such as Humalog, Novolog and Fiasp. All of which are priced off the chart. Diabetics need a pump that uses the Humulin at $24.99 a vial. And of course, Big Pharma just wants them to use the expensive insulin. Sigh.

 

[Northeast Agent]

Thanks kgmom and somarco.

The client just called before I got to him. Turns out, Medicare is paying for his Novolog after all, he just listed it on his drug list I sent him. He said it's through Walgreens Specialty Pharmacy in Summit, NJ.

Going forward, I'll have a separate drug questionnaire for diabetics using a pump. I'll need to know if their pharmacy is approved to bill Part B, etc if I recommend a different one the next year.

I'm also going to learn more about the diabetic supplies, drugs etc so I'm not caught off guard again like this.

 

[somarco]

I'll need to know if their pharmacy is approved to bill Part B, etc if I recommend a different one the next year.

Some folks may not know about the Part B coverage. Those with MAPD plans don't have the luxury of having Medicare pay for their juice.