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This blog is the third in a three-part series in which we discuss Medicare coverage for diabetes supplies.
Medicare Part B covers insulin pumps worn outside the body — including the insulin used with the pump — for some people with Medicare Part B who have diabetes and meet certain conditions.
What are those conditions? You must meet either criterion A or B.
Criterion A states that you must:
Criterion B states that you must have been using an insulin pump prior to enrollment in Medicare, and that you have documentation of testing your blood glucose four times a day during the month prior to Medicare enrollment.
In addition, it's important to note:
What are your experiences with insulin pumps and Medicare?
Have a good week.
Nancy Klobassa Davidson, R.N.
Peggy Moreland, R.N.
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im type 1 and about to go on medicare. my pump will not be covered so i'm left with few choices and lots of changes. everyone is saying how sorry they are........my dr., and my omnipod supplier......makes me feel so much better...no.....I am not a happy camper right now..........
I STILL DON'T KNOW WHERE TO GO TO FIND A SUPPLIER FOR THE INSULIN AS WELL AS THE SUPPLIES? IS THIS AN UNANSWERABLE QUESTION?
My approved mail order company told me to go sit in a corner and die. If I am not a type1 no pump no how no way....even tho i have used my pump for nearly 9 years. This was just for some cartridges and infusion sets, wait until this fall when time comes for a new pump.
Medicare questions: here is a number for you to contact Medicare and find out the contract supplier in your area. 1-800-633-4227. TTY users call 1-877-486-2048 or Medicare.gov/supplier and enter your zip code.
I have been using an insulin pump for 13 years. The problem I am having concerns Medicare and where to get insulin. I can't find a medical supplier or pharmacy that will bill my insulin to Part B as a durable medical supply. For several years I got my pump supplies and insulin from CCS Medical. They will no longer bill insulin to Part B. Same story with Liberty Medical.
For awhile I was getting my supplies and insulin from Mini Pharmacy in Los Angeles. The last time I called to order I could not get my supplies and insulin because my primary insurance was Medicare and they could no longer bill Medicare. My current supplier for pump supplies does not handle insulin. I have checked with Walgreens and Rite Aid with no luck. I had to pay over $200 co-pay to Walgreens for 4 vials. When it was billed to Part B I payed $0.00. Any suggestions?
To receive insulin for a pump, my doctor writes a prescription which I take to a CVS for the purchase. We provide information from the doctor that I have an insulin pump and it is then billed to Medicare. The doctor must supply his physician number. If they don't want to do this under Medicare, show them the book which states insulin for a pump is paid for by Part B Medicare. They will charge you 20%. If you have a secondary plan that pays everything Medicare B does not, they will bill that company and there is "no" charge.
I am a Type I diabetic and I love Medicare! Maybe some of the people responding had an employer paying for their insurance and did not realize how the cost had gone up. I was a small business owner and my insurance alone (not counting my husband) was $1200 PER MONTH. With that, I got deductibles, and certainly, it didn't cover the full amount of supplies - plus my insurance only covered a very small amount when I purchased my first pump. Now, I happily pay my Medicare payment and an additional $240 per month for an additional policy and everything is covered! If you are unhappy with the additional money you pay, save money by buying a better secondary policy. There is nothing for FREE. When I purchase insulin for the pump, I carry the part from the Medicare book on insulin purchases for pumps. It only takes a few minutes to argue with the pharmacy with that and mine is billed to Medicare. My 20% is picked up by my secondary policy. The pharmacy files the paperwork and I receive confirmation that it has been paid. No, they will not cover CCM. Yes, I'm unhappy about that but I just test more frequently. And, every person that needs an insulin pump should see a doctor every 3 months. If you have the secondary insurance, as I have, the doctor visit also doesn't cost anything as the secondary picks up what Medicare doesn't. There is no cost to me for the lab costs either. It also pays for my yearly eye exam for diabetes. I'm a happy camper!
I spent over an hour researching Medicare.gov and talked with several live representatives and I did not get a direct answer to the question. "Are CGM sensors covered by Medicare?" I did not see it listed in the DME supplies. Does anyone have any experience with Medicare and CGM sensors?
are the sensors for the pump covered by medicare?
for the person who thinks medicare patients are stupid to think their meds will be paid for...we pay our own way. we pay a premium for medicare just like and more then private insurance. I also pay (besides the 130 to medicare) $170 for a supplement and another $80 for meds insurance. Now they are backing out of the deal and not paying insulin???? All this on my social security payment of $1200. even though I worked my life and put into social security...how about they give me my money back and I'll pay full price for all???
In the last year, medicare will not cover insulin for pumps anymore. I have changed supplies three times and cannot find one to supply insulin for insulin pumps anymore so have to pay for the insulin instead of it being paid under durable goods. horrible...
Medicare insulin guidelines question. If you are insulin dependent non-type 1, what are you to use if your doctor prescribes insulin therapy? If it is not covered are you they suggesting that you not treat your diabetes? I have never been on oral agents with the exception of Metformin as an adjunct therapy only. Who is prescribing; my doctors or Medicare?
-Rebecca RN and LADA-fully insulin dependent
I'm an insulin dependent type 2, probably an LADA diabetic, who has only been on insulin since diagnosis. I switched to an insulin pump approx. 10 months ago and it has been no less than life changing. I feel better. More energy. I have been able to lose weight since I am no longer "chasing" yesterdays does of long acting insulin, which is said to not have a peak.Based on what I feel & my testing results I do not agree. My control has always been excellent due to my behavior. I have still had complications of DM.I feel the Medicare 2001-2004 criteria for pump therapy for non-type 1 diabetics is more and more outdated.Other countries have documented benefits. Patients are reporting benefits. The criteria is punitive for patients taking excellent care to control their DM vs patients who are out of control, that in itself does not make any sense.I thought using a pump would ultimately be more expensive than multiple daily injections (I was doing up to 6 a day).After 10 months the costs are break even with the added cost of long acting.It is time to re-evaluate pump therapy and join the modern age and use the excellent and continuely improving technological tools available to us to make DM treatment with intensive insulin therapy more palatable, comfortable, available and help those of us desperately trying to prevent complications by trying to maintaining excellent control.
Thank you, Rebecca RN
I'm a type 1 diabetic and have been for roughly 30 years. In addition I've been on Medtronic MiniMed insulin pumps (several different upgraded models over time) for approximately 15 years. I'm being told by my supplier of reservoirs and infusion sets, Medtronic, that it is a Medicare requirement that I must see my physician every 3 months (they claim this to be a Medicare requirement) in order for them to refill my prescription. I meet the Medicare criteria for pump use and haven't been able to locate any information on the Medicare site that I must visit my physician this often (4 times per year). Can anyone enlighten me? Thanks!
Pumps and Medicare are not compatible...unless you have $INCOME$
With a job, I paid $0 out of pocket and my pump, insulin and infusion sets/resevoirs were covered and cost me $5 - $15 per month...now that Im on Medicare, I pay $100 part B premium...anohter $160/mo in MedAdvantage fees, and pump supplies cost me approx $200/mo on top of all of that. So, after 10+ years of pumping...and 30+ years of Type 1 diabetes, I am now back on a sliding scale and 7 shots a day.
You are correct, A C-peptide test and a conncurrent fasting glucose are required by Medicare. Nice catch.
This information that is given here is not correct. For one thing, you need a c-peptide test with concurrent glucose >= 225 in addition to criteria a or b.
How stupid are these people in Medicare to think that they will not pay for injections of insulin???Lots of people cannot afford a pump or insurance will not cover it so this is why you pay $100 a month for???
Liberty Medical is my supplier for pump supplies and they told me that I would have a fasting blood sugar and a C-Ppeptide test doine at the same time.I didi this, had a bad infusion set so my FBS was 338 that day and now they refuse to send me supplies saying that Medicare will not approve them. Is this true?Also, M<edicare has the dumb rule that they will not pay for Insulin UNLESS it is used in a pump!!!How dumb is that for the people who cannot afford a pump????
I don't think this is right. A C-peptide test and Fasting Glucose is required in order to have Medicare pay under part B. So, if you know for sure and can document this criteria B please post it. I'm type 2 and been on a pump since June 2011 and will turn 65 in April and not able to qualify under part B. The c-pep test is to "weed out" the type 2 diabetic.
Any info you have please post...
My mother has been a practicing Type 1 for the past 25+ years and a new Medicare recipient. She recently found out that although Medicare covers her insulin pump, they DO NOT cover the sensors and AGM Transmitter necessary to use it, the cost of which is upwards of $80 a week. How can Medicare expect Type 1 patients to pay for these out-of-pocket?? Is she the only one encountering this problem with Medicare coverage??
Can you tell me how to find a Medicare contracted provider that will supply the insulin used in pumps.
Iam a practicing Type 1 for the past 44 years. I was diagnosed in 1967 at age 30. My Medicare HMO Blue provided me with an Animas Pump 3 years ago but now I could use a Dexcom CGMs to help with hypoglycemia unawareness and the dangerous unsafe conditions that very often occurs. How can I get my health insurance provider pay for a CGMs when they say that my health is important to them?
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