Hi All,
Totally at a loss here- can’t get any consistent info from the Medicare desk or insurance providers, and I’m hoping someone here can share their experience to help me decide what plan to get on.
I recently lost my job and got on Part B, but need to sign up for an Advantage or Part D plan- but it looks like my CGM and pump supplies are going to cost me a fortune. This may be worse in my area (Brooklyn, NY) but if anyone can share some experience with their Insurance providers and Part B- that would be most awesome.
Thanks in advance!!!
@art00r Welcome to the JDRF TypeOneNation community Forum!
My solution since I retired 13 years ago has been United Healthcare Advantage Choice Plans. There has been a few plan changes for my zip code but ALL have covered upgrade in pumps [20% co-pay of Medicare discount final cost] and $0.00 co=pay for pimp supplies and CGM.
I found the OFFICUAL Medicare site very helpful.
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I use a Medicare Supplement which covers the 20% co-pay after meeting the small Part B deductible (<$200). Those on Part C (Medicare Advantage) plans tend to be more limited in choice of pump. There is also a blood test called C-Peptide you must basically fail in order to qualify on Medicare. If you are a Type 1 of long standing, you will fail. Type 2’s have higher results and are not eligible for the pump.
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Here is where it gets tricky because Medicare and a Supplement will be higher premiums but in the end lower total cost because after the $240 copay in January you will not pay a penny. If you go with a Supplement in reality you are on Commercial insurance. So you will have networks which can change at any moment, doctors you will not be able to see which can change at any moment, and supplier that you will have to buy from. You will likely pay nothing extra but the headaches will be constant. It is estimated that 80% of claims are rejected by Advantage plans and then the patient has to push in order to get the claim paid. So I use Medicare and a Supplement. By the way I hope you know that Insulin for diabetics on a pump, are part B. While you have to have a Part D, never get your insulin by part D. Again after your deductible, all insulin is free. Walgreens is the easiest to deal with. So it is really up to your tolerance for the hassles of Advantage plans, and your ability to pay a little over a $100 a month in Medicare Supplement plans but the Supplement MUST pay everything after the 80%. There are no networks and no limits. You can buy supplies from anyone.
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I agree Walgreens is probably the best pharmacy to get your insulin for your pump. I also think it depends on the pharmacist. Many times, after a day or two I will call for an update on my prescription and will get strange responses like “Your doctor didn’t fill out the prior authorization form we sent him”, Medicare will not answer the phone, etc. Usually after 5-6 days and my insulin prescription is still not filled, I will call the Walgreens Medicare number and they will over ride the claim and clear my prescription.
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That’s why I said they are the best. CVS outright refuses and Kroger will charge you even though it’s supposed to be free. The only other that will do it in my area is Walmart and I have not tried them yet. I have Walgreen’s corporate number because the local pharmacist have no clue and they have to call to find out why it’s not going through. Walgreen’s corporate people delay at the end of the month because it helps their monthly numbers. When I call the corporate number 9 times out of 10 they want my weight. When I say this is not a requirement for Medicare to pay for this, they just say it is our requirement. I then say will your local pharmacist needs to know this so a life saving medication is not delayed and if you do this again, I will contact a lawyer. They then say, the pharmacy can now put this through. Games games games but it is still easier than Medicare Advantage in my opinion.
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I have been on Medicare for 10 years. I use 9 vials of insulin every 90 days. Every 90 days I bring my prescription to Walgreens. On the back of the prescription I write in all kinds of information -Bill through Medicare Part B, On insulin pump, last physician visit date, my ht,and wt.,pump type, serial number, when purchased etc.etc. I have never had it filled smoothly. It always take 5-7 days and multiple phone calls before I can pick up my prescription. I really don’t understand it. Every time I tell myself, “I have to find another pharmacy”, but I never have. I stopped at a small local pharmacy last year and asked if they would fill it. They were hesitant, but did say they could give me a 30 day supply each month, because they could not afford to have their money tied up before they were re-imbursed.
There were times that I was so frustrated I almost gave in and told them to bill through Medicare Plan D and pay the copay.
I don’t understand why this life sustaining medication is so hard to obtain.
Not sure if the problem lies with Medicare or the Pharmacies, but there definitely is a problem.
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Thanks all for sharing your experiences. I’m still undecided, but I have a lot more to work with. I think I’m heading towards a similar solution with a Medigap plan along with A and B. Hopefully, things will go back to normal now that the holidays are over and I’ll be able to get some people on the phone and be more prepared with questions.
Edmund- there’s a blog here: Medical supply company recommendations - #2 by wadawabbit . Get your stuff via mail-order. Sure there are always headaches, but you can do it from home!!
Art- I don’t have any problems getting Dexcom sensors and pump supplies from Wellstart. My only problem is getting insulin from Walgreens. If anyone has any success stories with other Pharmacies, I would love to hear.
I use Walmart for my insulin. I use a pump so it is covered by Part B. I have used other pharmacies but I have better luck with Walmart.
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My husband was on BCBS Advantage and also UHC Advantage plans in different years. His new t-Slim pump straddled both companies. He also used Dexcom G6. In both cases, the CGMs were 100% paid for by both insurers. He did not need a Receiver and used his phone instead. The pump was paid for over 12 months under DME coverage, which was a 20% copay. His infusion sets and cartridges were also 20% copay. The infusion/cartridges cost us about $18 per month under his top-tier expensive $164/premium BCBS plan. They were $21 per month under his very inexpensive $73/premium UHC plan. In both cases we used Byram Healthcare, a preferred vendor for both. I believe the pump DME copay ran around $58 per month for 12 months, then that payment dropped off. In Minnesota, Medigap coverage is exceedingly expensive, hence the reason we used Part C Advantage plans. UHC offered many more perks that saved us at least $50/month. I had no disputes for DME coverage under both companies. Hope this helps!
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I’ve been on a pump for 23 years and never ran into a problem with getting pump supplies or insulin covered until I started Medicare a year ago. I have a Supplement plan which pays well. The problem is Medicare has denied my insulin and pump supplies for a year now. I will have an appeal hearing soon after three appeal denials. It seems the problem is related to Medicare’s documentation requirements and my DME provider not sending the proper documentation. I would think the provider should know Medicare’s requirements. As the beneficiary I can’t get Medicare to give me the exact reasons why it has not been approved. The provider keeps saying they have sent everything in. Today I learned from a legal assistant with the Medicare appeal group that Medicare does not recognize I own a pump since they didn’t pay for it. They want the EOB from the previous insurance company (CIGNA) that shows I received the pump and a copy of the doctor’s order for the pump. Luckily I was still able to go online tonight and find the EOB from Sept. 22. I am waiting for the doctor’s order. I hope that is all that is missing and everything is written how Medicare wants it. The provider company told me today they already sent those documents into Medicare. I will have to wait for the official Appeal Hearing in a few weeks to see if Medicare will finally approve my insulin and pump supplies for the last year. If not, I will have to start over and get a new pump 3 years early. It has been so stressful. So if you start on Medicare and already have a pump, find that old EOB from your previous insurer. Also I enjoyed reading about DME companies people are using as I may change companies due this major screwup. I never had an issue getting supplies while I was getting it through my work insurance. It was easy to even have a little build up for vacations. Medicare’s requirement that you receive your supplies a day or two before you run out is outrageous. Every three months I have no idea if my supplies will arrive in time or not. Although I am so disappointed that my DME company did not do the proper filing the first time or the 3 other times afterwards, they have been sending me supplies because they believe Medicare will finally approve it. I hope they are right. Medicare Plan G has been great for everything else, but this. They approved the CGM Dexcom, but of course I can’t build up a reserve based on their regulations. Crazy!
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Sorry to read of the frustrations that you have been through, Mary @mkenni. My adventure in getting a new t-Slim has been very different from what you’ve experienced.
Knowing that the Medicare 5-year extended warranty" on my t-Slim was expiring on January 11, 2024, I called Tandem Cares the last week of December and told the Representative that I wanted another t-Slim; she took my information and said she would be in touch on January 12th. On Wednesday January 17th I got a call from Byram telling me United Healthcare Medicare Advantage posted an approval letter and that my pump would ship; delivery today January 19th [signature required] - exactly one week from beginning to end, and without me needing to get involved.
Bottom line, and this is the third pump I’ve received through Medicare since I retired at age 70, let the experts do all the work for you. This is the process that both Dexcom and Tandem have served me very well.
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I ended up signing up for original Medicare and Medigap plan N and part D thru AARP United Health Care plans. My coverage starts Feb1, so I don’t have any experiences to share yet, but will let you all know when I do.
Thanks, Dennis, for you encouraging email. I am hopeful that once Medicare acknowledges that I own a pump, it will be smooth sailing.
It is not the pharmacist at all so try not to blame them. It is the corporate people that govern billing and they are violating all kinds of Medicare rules in what they are doing. I suggest calling or submitting a ticket with your state’s health department and my Pharmacist are so frustrated with it, they gave me the corporate Walgreen’s pharmacy telephone number. All pharmacies are so short staffed they do not have time to deal with this yet they are the ones we call. So I just call the corporate number when I see “Delayed by Insurance.” They either ask for my weight, height, or pump serial number. NONE of that is a Medicare requirement. I have also noticed that if your prescription is submitted or due at the end of the month, forget it. They do not want it filled because it makes their financials look bad. Call the corporate number if you know it’s being delayed because of Insurance. The number is 888-281-0590. This is only for those on Medicare.
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wow!, new to the board, T1D for the past 34 years , turning 65 soon, will be signing up for medicare, could not believe what I was reading, hoping it all gets straightened out, have been doing my due diligence , thank you for posting.
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@Air59 Welcome Eric, to the JDRF TyprOneNation Community forum!
Here you will see many personal experiences expressed and the reports seem can be very different. I for one have had a very positive Medicare experience, and as you say due diligence is necessary to make certain you select the correct policy; I retired when I reached 70 13+ years ago and during that time I haven’t had any difficulty getting three pumps of my choice and all the necessary CGM. Every year I reevaluate my coverage - a tool on Medicare.gov posted 33 choices for my zip-code. I use MedicareAdvantage Choice, the highest monthly premium allowed, but by far the lowest net annual out-of-pocket, monthly premium added in.
On January 12th, the day after my t-Slim warranty expired I spoke on the phone with a Tandem Representative [I had introduced myself to her in late December], she got the ball rolling with both United Healthcare and Byrum, my choice of the many Medicare suppliers. My new t-Slim has been attached to me and working well since January 19th. Bottom line: I let the professionals take care of me and I DO NOT try to tell them how to do their work.
Thank you for your excellent documentation, I am on , I think my fourth Medtronic pump, 760 I believe, but am interested in the Omni pod and what accessories that go with it , I will look into the tandem , again Thank u.
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Hi Eric @Air59. Welcome to the forum. JDRF publishes a great resource for diabetics navigating Medicare
If you pick Part B and are interested in how things work I recommend reading the cms.gov docs on diabetes supplies based on a discussion I was having today with a few T1Ds already on Medicare.
External Infusion Pump LCD Note the C-peptide test and see a doctor every 3 months requirements
Glucose Monitors LCD