I went to Walgreens today to fill my insulin prescription for my pump. They told me that Medicare had been hacked and they could not bill it through Part B. They said my only option would be to bill it through Part D and pay $105. They said I would have to pay and Medicare would reimburse me? I called Walgreens Medicare number and was told that it could be done they had to bill it through Portal JobAid or IVR? When I returned to the pharmacy they said they couldn’t do it?
I know Pharmacies are understaffed but it kind of leaves the customers out in the cold.
@edmundo there was a hack recently that was and perhaps still is affecting insurance claims and is affecting patients, hospitals, pharmacies - pretty much the gamut. I recently transferred my prescriptions to a new CVS - thankfully there were no issues, perhaps because they were already in their system - I’m not sure but the issue may be with determining pricing for newly issued scripts.
Some work-arounds were/are being put into place so claims can be processed through another system or company, but the process will be slower. I don’t know why they can bill through one party of Medicare and not another but apparently that’s the way the system is set up. Unfortunately some patients may need to pay up front and I imagine file a claim to recoup their funds.
It’s not the fault of the pharmacy or their staff - their hands are pretty much tied.
This article may explain it better:
Well if Medicare was hacked, no one knows about it. Walgreens will say anything. Do not believe anything they say. First call Medicare.
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Hi Larry,
It’s so easy to become trapped in this run around. I am so thankful that when this starts to happen a nurse at my endo’s office will step in for me to overcome the pharmacy misinformation. She will stay with it until it is resolved. The pharmacy is actually thankful for her help as they want to fill the RX, too, but they don’t always know how. So many new employees without someone to help train them.
I find Medicare can be a bit difficult to work with unless your question is very specific and you have a code for it. They now say they can’t guarantee something will be paid. I ask the medical provider first to see if they accept Medicare which makes me feel that some will be paid. Any further procedures and I ask the billing office for the medical codes. It is a terrible time sink.
I am in the process of signing up for medicare for the first time. I use omnipod and am wondering if anyone here has figured out which medicare Part D insurance companies have some decent coverage for Omnipod. I am unable to add it to the medication list and am struggling with finding clear information on the insurance websites, talking with insurance companies and talking with Medicare was useless as well. Art00 I am interested in how AARP United Health care has worked for you thus far.
What part D insurance and what medigap plan do you use? I use Omnipod and trying to get some info about coverage.
Part D is only used for my preventitive BP and Cholesterol meds. They dont have anything to do with my diabetic insulin pump, sensors, supplies, test strips. I change part D every year depending on who is the lowest. Anthem BC/BS has always been my Supplement Medigap. Never had a single issue with them. Your insulin will all be free but you have to get it usually from Walgreens. CVS refuses to do insulin under Part B. I hear Walmart will also do Part B insulin but never tried them. Medicare covers everything thing including the pump, sensor, and all supplies. Anthem pays the 20% Medicare doesnt. After the yearly Medicare deductible, I pay zero for my Diabetes supplies. The Anthem plan is about $130 a month but if you add up all the costs of Insulin, the pump, sensors, supplies, and test strips it more than makes up for it.
Hi Victoria,
AARP/UHC works, but I find it expensive and complicated. I will be shopping again at the end of this term. That being said, I don’t think I made the wrong choice, I’d just like to do better.
I’m in NY State, and things are different by each state, so I don’t know how it would work for you or what your other choices are. I ended up using Chapter (getchapter.com) to help me organize my thoughts about these plans though, since I couldn’t decided by myself. They also offer some ongoing support. You may want to reach out to them- There is no charge.
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@vpillard Welcome Victoria to this JDRF Community Forum.
The search for and understanding the many Medicare Parts can be confusing, so I admire your desire to begin early. Medicare Part A and Medicare Part B are available domestically with Part A being automatic upon enrollment (I waited until I reached my 70s) and Part B is an optional with benefits the same across the Country. Parts C through K differ by region and not available in all regions and specific benefits and costs can be different. An example, Medicare Advantage Plans may or not include drug coverage. The Plan that has been totally awesome and cost effective for me for 14 years may not work for you. May I suggest that you:
- Gather together “your needs” and out- of-pocket costs and expenses. Include doctor co-pay, covered prescriptions,
- Access Medicare.gov (the no-cost official government tool) and enroll (saves needing to reenter medications, etc., for cost comparisons at a future date)
- Upon entering your address or zip code and type of coverage you think you may need, a list of plans available in your area will appear;
- Choose from that list; ex, PPO, PMO, with/without drug, etc.
- If you add in your prescription information, the program will project your total estimated cost per plan and expected out-of-pocket.
- Use this to narrow your choices and call/email the contact person provided to get your specific questions answered.
I have been continuously using the AARP/UHE Advantage Choice Plan which has changed/improved for me during my use.
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Hi Victoria. Finding a Medicare Part D plan that covers both your medications and Omnipods takes a little extra work.
- Start by using Find a Medicare plan to search for Part D plans
- Make a list of the plans that cover the medicines you need
- For each plan on your list click the Plan Details button then click the Plan Website button
- Use the plan’s website to find Part D plans in your area.
- As I was making this list I found some plan websites let me add Omnipod as a drug. For websites that don’t you’ll need to find the plan formulary, aka drug list. This will be a PDF. Search the PDF for Omnipod
- If Omnipod isn’t found, the plan doesn’t cover Omnipod and cross the plan off your list. If it is found note the Tier and then figure out the price. If the particular Tier only covers a percentage let us know and someone here on omnipod can check their claims history to get you an example price. Make a note on your plan list of what you find
- Repeat for the next plan.
I had problems like this with getting my insulin covered when I first went on Medicare, but CVS knew I was qualified and they did not refuse to give me my insulin. I got a denial of their appeal at one point, and knew that they had not proven I owned my pump. I found the receipt for it and offered to send a copy to them, but they insisted they only needed the date I got my pump on my previous insurance. Their claim was denied, so I filed an appeal myself, including a copy of my receipt for my pump and pointing out that they had already been covering my pump’s infusion sets and cartridges for a year, so they must already know I own a pump. Well, that worked, and CVS was reimbursed by Medicare, but only for a year’s worth of insulin, and I had been on Medicare for over a year at that point. They lost a few hundred dollars, but all has gone smoothly since.
@Air59 , was curious about coverage of Medtronic, i have 780. I’m planning early for what I should do next year.
I have done everything folks here suggest. I have a spread sheet with my meds and the insurance plans on part D. I have enrolled in Parts A, B to start on the first of my birthday month and also to allow me to save what I research on the medicare sites pertaining to Part D. I have looked at almost every insurance website and find most of them difficult to navigate and find clear information. Many say Omnipod is Tier 4 and I need to pay eg 34-46% of the retail price. I have called the insurance companies, a pharmacy and omnipod and get different quotes for retail price. After many, many hours of going in circles I am finally leaning toward the Aetna Silver script plus plan with one of the top copays. They cover another non generic med I need which many plans don’t and for the moment anyway cover Omnipod as a Tier 3 ($47/month). I will believe it when it actually happens. I have found the free SHINE advisers not helpful which is too bad. I have a call into a pharmacy school in my state that I have heard helps find the best plans in cases like mine. I will hopefully will hear from them in the next few days in the hope they back up my finding.
AARP looks good - it does cover Omnipod but again it does not cover a different medication that I am on. Arghh
Thanks to everyone for your advice.
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My apologies if this provokes and eyeroll, but is Kaiser Permanente not an option? I am a member (and will be a former employee very soon) of KP and am trying to decide if they are the best option or if I should go with another provider. I use the TSlim 2 with the Dexcom G7 and like both. Currently, both are provided with no co-pay which is soon to end, I’m sure, so I am curious as to my options and thought perhaps someone here might know.
I will also search further on the board.
Thanks!
@AGuest01 Welcome Shelby to the Breakthrough Community Forum!
Like many insurance program benefits with Medicare Advantage plans can vary by your location. I suggest for making your choice, that you visit the government official site [medicare.gov] , enter your zip code and find plans available to you. You will have an opportunity to enter your prescriptions, etc. and the program will provide you with estimated out-of-pocket yearly costs.
check the various offerings and see if your physicians are In-Network and use these guides to select your plan choice(s). Each plan choice will provide a phone number where you may ask specific coverage/cost questions.
Good luck!
Thanks for that link to medicare. I put in my zip code and looked at plans. Do you know when it says Total for premium and drug costs on Advantage plan, does that mean per month or total for the year? So, would my costs possibly be $420.00 per month for medication? I only take 3 meds. I included insulin, which actually by pump, so that goes through Part B, right?
Hi @HighHopes . Your post was a reminder that I need to continue my research - I’ll be eligible in April. I just wanted to say, funny forget to check GoodRx for drug prices in your zip code. My pharmacy has occasionally used them to get me better price on a medication. Prices can vary greatly.
Ask you’re pharmacist if they can apply GoodRx prices in your area if you have insurance - I don’t know if it makes a difference.
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That’s a good idea. I checked further on a Humana advantage plan and found some reasonable plans that civer my meds except for one where I’ll try to use an RX discount.
I’m also considering a Medigap policy. If I don’t select that now, I lose the right or am penalized it seems, but they are expensive, so…….hard decisions.
When do you have to device decide? I turn 65 in April.
Total Drug & Premium Cost (for 2025)
is the estimated cost for the whole year.
$420 is $35 (covered insulin copay cap) multiplied by 12 months.
You are choosing between Medicare Parts A&B OR a Medicare Advantage plan. If you choose a Medicare Advantage plan it will cover an insulin pump per the limitations in the plan documents. Be sure to check for which DME companies are in network. The Medicare Part B document for pump coverage is https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?LCDId=33794
Conventional wisdom is people who are retiring now and were diagnosed with T1D as a child should choose Medicare Parts A&B instead of a MA plan because there is no way to predict which complications and how many complications due to T1D you are going to face later in life. A care team of 20 doctors is perfectly normal. Finding a MA plan with a large enough network of doctors with appointments available when you need them 20-30 years from now can be tough. Technically in the future you can switch from MA to Parts A&B. What makes that impractical is that Medigap plans can deny you coverage based on preexisting conditions if you sign up after the turning 65 enrollment window. Part B covers 80% of pump costs, the Medigap plan is what makes pumps, supplies and insulin for pumps free for most people on Part B.
Good luck and reach out if you need help.
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