I’m navigating the Medicare approval for insulin use in pumps….in particular the Omnipod. The language for Medicare coverage for insulin under Part B states it does not cover insulin (unless use of an insulin pump is medically necessary) and Part D pays for insulin that isn’t used with a “traditional” insulin pump. Is the Omnipod considered a “ traditional “ or does the tubeless feature make it non traditional?
In one of the previous questions, someone stated that Medicare is now asking for which pump is being used when billed.
If Omnipod is not considered a traditional insulin pump by Medicare and it is covered under Part D ( rather than Part B) like all the other pumps, should I expect that Medicare will not pay for insulin used in the Omnipod???
Just a note, the new legislation that says Medicare recipients will only pay $35 for insulin does not address the fact that the “billed cost” will be added to total prescription cost which will push us into the DONUT HOLE quickly!!
From the Omnipod web site,
" ### Omnipod® is covered under Medicare Part D.
https://www.omnipod.com › coverage › medicare
Omnipod® is covered under Medicare Part D. Insurance can be complicated - let us help! The information below includes tips and …"
As for insulin coverage, if you have coverage under Part D Medicare (which covers drugs including insulin), then I suspect the $35 maximum cost for insulin should also apply. You should double check with the specific provider of the Part D Medicare plan you have or plan to purchase to make sure this is correct.
In general when it comes to Medicare and insulin pumps Part B will only pay for insulin used in pumps bought and paid for using Part B. Specifically the Omnipod is not classified as “Durable Medical Equipment” (DME) which is part of the Part B infusion pump requirement therefore Part B will not cover insulin for the Omnipod.
Note that the $35 deductible for insulin applies to Part B as of July 1, 2023.
I found two resources that may help you navigate the medicare minefield.
JDRF has a nice illustrated guide to medicare coverage of pumps, CGMs and insulin
Medicare published a FAQ about the changes to insulin coverage with the dates when the changes become effective.
The following quotation comes directly from the Medicare website:
Your costs in Original Medicare
“The cost of a one-month supply of each Part D-covered insulin is capped at $35, and you don’t have to pay a deductible for insulin. This applies to everyone who takes insulin, even if you get Extra Help. If you get a 60- or 90-day supply of insulin, your costs can’t be more than $35 for each month’s supply of each covered insulin. For example, if you get a 60-day supply of a Part D-covered insulin, you’ll generally pay no more than $70.”
One additional comment with regard to Part D Medicare–something you should take note of: Not all Part D Medicare coverage plans cover all the different types of insulin. For example, I know of at least one Part D plan that will pay for novolog but will NOT pay for humalog.
@barb2 ,
The issue with Omnipod is it is not durable medical equipment (lasts 3 or more years) since it is a one & done use. One the other hand the PDA is used for more than 3 years.
Reading here and Facebook diabetes groups about Medicare, indicates POD coverage depends on how the prescriber writes the Rx for insulin. PODs are pumps and therefore should be covered, if the script is properly written.
I understand the logic that the Omnipod 5 is not covered by Medicare Part B because it only lasts for 3 days per POD. BUT….HOW did the Dexcom G 6 get covered under Part B? It sounds like the Dexcom G 7 that has a transmitter and sensor which lasts only 10 days will be covered under Medicare Part B. How does Medicare justify these confusing/ conflicting decisions?
Dexcom got classified as DME because the system as a whole includes a receiver which is durable.
The constitution doesn’t say the government has to make sense.
Medicare is complicated and everyone’s situation is a little different. What about your situation makes getting insulin covered by Part B better than having it covered by Part D?
All type 1s using an insulin pump get insulin under part b and it’s all kinds of pumps. It’s been Medicare policy for over a year now. Do not let a part D insurance company take your money. You will have to get your insulin usually at a Walgreens pharmacy but free is free. By the way CVS can not usually make it work. Your doctor will have to go through some paperwork submissions but after that you can get 3 months at a time free after your part B deductible.
I have a question that NO ONE, including Medicare, can’t answer for me. I am an adult-onset Type 1, on a Medtronic 780g pump and Dexcom G7. up until August 2023, I was getting my Novolog or Insulin Aspart free, under Part B. Then, suddenly, I had to start paying $105 for my 3-month supply of 12 vials. The pharmacy told me that Medicare is the one who bills my supplement. I called Medicare, (a waste!) and they told me (or read to me) their standard answer -”Medicare pays 80% and you or your supplement pay the rest of the 20%.” Several agents always said the same thing. Other online communities have said that the pharmacy bills the supplement. Which is it?
And has that $35 per month cap on insulin cancelled out the billing of Medicare supplements on insulin in Part B? I still do get it through Part B, but I still have to pay the $35 per month for it! I realize it could be worse, but over $400 per year for insulin is hard for this 75yo Senior! Any suggestions? And I apologize for this long post!
That is an excellent question that I’d also like the answer to. The pharmacy is supposed to generate the claim and it is supposed to come back as paid in full when you have a supplement plan. What the pharmacy computer is doing in the middle of that is a mystery. When I’ve talked to people about this it has always been the kids working at the pharmacy causing the problem.
First things first, have you verified the insulin is showing up on your Part B statements? The second thing to check is does your supplement plan have a deductible that you haven’t met yet this year? If your insulin is showing up on Part B and you’ve met your deductible, if any, call your supplement plan and ask them how to get reimbursed for the copays. Also ask if the plan has pharmacy benefits BIN, PCN and GRP codes. Or if your supplement plan came with an ID card the info may be there. Which pharmacy are you using? I know some specifics about CVS and Walgreens, less about Walmart but there’s a pharmacy tech at the one near me that is unstoppable that I can ask.
Medicare is very helpful for claims and for telling you what is covered and what is not, but they can not help you with something your pharmacy does. ANYTIME they tell you it’s $105 for a 3 month supply, they are filing with Part D. Ask for the manager and tell him you need a BOLD note on your account that every claim has to be via Medicare Part B. If you have been charged $105, they have for me, and will refund that money very quickly because it is a federal law. I have only had that happen once, and it was a new pharmacy tech. The Pharmacy Managers all know exactly how to do this but keep in mind, you may be the ONLY diabetic with a pump that ever comes into your pharmacy. Don’t get upset with them, just be firm that you should not be charged anything if it’s filed correctly. (assuming you have met your Part B deductible) Be very careful with the first prescription in a new year, all these chains WANT that deductible money and they will file it wrong if you don’t contact the right person. Keep in mine also that even if it’s submitted correctly, you are gonna have delays. I use Walgreens because my doctor said they are best at Part B claims, but the corporate people do not like these claims and will delay. If you see a pending insurance my local pharmacist even gave me the corporate claims number that he will have to call. The barrier is usually, “how much do you weigh, what brand is your pump. etc. None of these are Medicare requirements, just delays. Walgreen’s corporate claims number is 888-281-0590. Again if filed Part B and you see Pending Insurance, call that number and it will be cleared in minutes. We should not have to do all this, but it’s the USA Way.
Regarding deductibles, keep in mind there’s a delay between when you pay for a service and when it shows in your record and is applied towards your deductible. I placed my first order of Dexcom sensors a couple of days into the new year and the cost covered my deductible - but I still had to pay for prescriptions that I picked up several days later because the deductible hadn’t gone through - and unfortunately that could take a few weeks.
Thankfully it was not a lot.
Larry,
Even though I confirmed with the pharmacy that they went through my Part B/DME, they told me the $105 came due.
While I have you, what is your opinion of my latest pharmacy (CVS) telling me they can’t bill to Medicare Part B/DME because that part is medical, not pharmacy?
Thank you for the helpful information!
There is a lot of misunderstanding and misinformation about this topic, so I will share trusted references and my oown experience.
As a baseline reference, BT1D has an excellent resource, though the page title is incomplete in that the page covers more than CGM: Medicare Coverage of Continuous Glucose Monitors (CGMs) Two additional references straight from Medicare: Insulin and https://www.medicare.gov/publications/12188-save-money-on-your-medicare-covered-insulin.pdf
Here is a summary:
- Do you use an insulin pump? If YES, then insulin is a Part B Durable Medical Expense (DME) along with pump supplies and CGM supplies; if NO, then insulin is covered under Part D
- Is insulin subject to a deductible? NO, absolutely not. To quote the BT1D link above, “Deductibles won’t apply for covered insulins for both Part B and D” and the Medicare link above, “you don’t have to pay a deductible for insulin.” There are some nuances, however, that I will describe next.
When BT1D uses the word “covered,” that means there are no formulary restrictions under Medicare Part B DME for a specific brand of insulin (example, Novolog vs Humalog), though the packaging of the insulin must be for use with an insulin pump: in other words, 10mL vials, not insulin pens or inhaled (Afrezza) insulin. I mention these other formulations because Medicare doesn’t limit you to only insulin used in a pump: these additional formulations fall under Part D coverage and are subject to the Part D plan provider’s formulary. If the insulin you need isn’t on the formulary, however, then you would have to go through the provider’s coverage exception process and work closely with your doctor on the exception justification. It is possible to get coverage exceptions for Part D plans. Regardless, under Part B and “covered” Part D the official Medicare cost for each formulation of insulin will be no more than $35/month or $105/90 days ($35 * 3 = $105).
As an example, if you use a Tandem insulin pump then 90 days of Humalog/Novolog would cost $105 with no deductible. If you also use Fiasp/Lyumjev insulin pens to treat hyperglycemia and your Part D plan includes the brand in their formulary, then a 90 days supply would also cost $105 with no deductible. In other words, the total 90-day cost of both insulin for the pump and a different brand of insulin for injection would be $210. ($105 + $105 = $210). Medigap plans enhance the insulin benefit: “If you have Part B and Medicare supplement Insurance (Medigap) that pays your Part B coinsurance, your plan should cover the cost ($35 or less) for each covered insulin.” My interpretation: once the annual Part B deductible is met, your Part B insulin costs will be $0 for the rest of the calendar year. Another reference dated April 2025 is found here: 3 Things to Know About Medicare Insulin Costs There may be a variation with the “covered insulin” formulary for Medicare Advantage (Part C) plans that combine Medicare Parts A, B, and D.
My experience and lessons-learned:
- I transitioned to Medicare after retiring from a large corporation with superb private health insurance.
- When I called them, none of the Medicare Part B DME suppliers listed at https://www.dexcom.com/faqs/medicare will provide insulin, likely because they don’t want the cost and risk of shipping insulin with freeze packs. Local pharmacies are the only realistic source for insulin through Medicare. My doctor recommended Walgreens, but none of the local pharmacy staff knew how to bill for insulin as Medicare Part B DME; they only knew about Part D claims. I finally found a local Kroger pharmacy that claimed knowledge of how to bill for insulin as Medicare Part B DME and I had to complete multiple forms in addition to providing a prescription.
- Medicare denied the first six months of Kroger’s Part B DME claims for insulin, though to their credit Kroger dispensed the insulin to me anyway. I knew about the denials because I regularly check the Medicare website for claims status, something I strongly recommend for anyone else on Medicare. I called Medicare and asked, “Why is Medicare denying insulin claims?” The response: “Medicare has no evidence you use an insulin pump. Maybe you should consider getting a new insulin pump through Medicare.” I had a new pump paid for by my previous employer’s insurance, so a new pump seemed silly and wasteful. Instead, I provded Kroger with a copy of my pump purchase receipt and told them, “include this receipt with your appeal to the claim denial.” Within a few months, Medicare paid the denied insulin claims and every subsequent insulin claim.
- Lesson-learned about Medicare Part B DME: Pharmacists are under-staffed, insufficiently trained and over-worked; they don’t know what they don’t know and when they hear “diabetes” or “insulin” with “Medicare” they think T2D and Part D. You may have to call multiple pharmacies to find the one pharmacist at that location who knows the Medicare Part B DME claims process. Unfortunately, you cannot rely on the expertise of the local pharmacy; instead you may need to educate them – consider using the references above. This knowledge gap at pharmacies is a major failing for Medicare and I have raised this probllem to the national BT1D Advocacy team. With my Part D plan, I have also been able to get multiple formulary coverage exceptions.
- Medicare also has several other rules for insulin pump coverage: (1) when you first transition to Medicare your doctor may have to submit results of a C-peptide lab to prove you have T1D; (2) the doctor who prescribes your insulin and CMG/pump supplies must treat multiple patients with insulin pumps; (3) you must meet in-person with this doctor every 90 days and the DME suppliers of CGM/pump supplies will ask your doctor for visit notes to verify.
I know this is a lot of information. Please feel free to ask questions.
Thanks for your information!
I’m with you on checking for the Part B claim on the medicare website being an important troubleshooting step for Janice because the pharmacy staff that are doing something wrong can’t be trusted to say which plan they submitting the claim to. And if the claim is being denied of course her supplement plan isn’t going to cover the copay. Could you please share the link to the login page and the steps you take to get to the Part B claims?
Since you are on Medicare Part B now Article - External Infusion Pumps - Policy Article (A52507) and LCD - External Infusion Pumps (L33794) are recommended reading. Review them once a year to keep track of changes for pump coverage. There are other documents for CGM coverage.
The primary login for Medicare is https://www.medicare.gov/account/login
If you don’t already have a login ID and password for Medicare, you will need to use ID.me, Login.gov, or Clear; the first two are also used by Social Security. The best written tutorial I found for checking claims is here: https://www.paulbinsurance.com/how-to-check-your-medicare-claim-status/
@spdif The reference for Medigap supplements covering insulin is at https://www.medicare.gov/coverage/insulin in the Costs section. I included a screen-grab:
