How to get Medicare to pay for Lyumjev

I use a med Tronic pump and have used NovoLog insulin for many years. With that insulin Eyes still tended to get some spikes after meals and when doing a correction would take 2 1/2 hours to get blood sugar to start dropping. At my recent endocrinologist appointment we discussed the ultra rapid acting insulin called Lyumjev. I have been using it in my pump for 3 1/2 weeks and it works great. I rarely get much of a spike after meals and then my blood sugar stays fairly steady until the next meal. When doing a correction for a high it will lower the blood sugar within 1 to 1 1/2 hours. I have original Medicare insurance with a supplement and also a part D for prescriptions. Since I use a pump we have been running my insulin through Medicare part B and then I have a zero dollar balance. The pharmacy tried to bill the new insulin through Medicare part B and it was rejected and also ran it through my part D Humana prescription coverage and it is non-formulary there. Has anyone had any luck getting this new insulin covered through their original Medicare part B? Or through any other kind of Medicare insurance plan? I see that insulin manufactures have some coupon programs to help with insulin cost but for some strange reason you cannot take advantage of them if you were on Medicare. So at this point my option is to pay full price for this most wonderful insulin has already increased my time in range from 84% to 90%. I feel better without the swings in blood sugar.

Hi @Pmaddix . I don’t have Medicare but from time to time my insurance requires my doctor to submit a special authorization - most often because another medication is now their preferred formulary so I need special approval to continue with my original one. I believe it was my pharmacy that let me know about the need for authorization - your pharmacist may be able to do some digging to see if that’s the case or if it’s simply not covered yet.

I don’t have Medicare, either. It may just be that the medication is too new to have been added to their formulary, which is frustrating. But you should be able to call them up and ask why it’s not covered and what you can do about it. Sorry I can’t be more helpful than that.

Thanks folks. My pharmacy is going to look into the possibility of a special authorization by getting information from the doctor and I thought I would also call Medicare this week and see if they can give any more information.

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Here is an update on what I have found out about insurance and this new insulin. We did a prior authorization for both my Humana part D prescription drug insurance and my Medicare part B. We discovered from the Eli Lily rep that Medicare part B is not yet recognizing this insulin as FTA has not officially approved it for use in an insulin pump. My part D insurance did except the prior authorization and will cover it as a tear for non-formulary medication charging me 50% of the cost of the insulin after my $445 deductible. So my first three vials ended up costing me $592. They are a little unclear as to what the cost will be now that I have met my deductible then apparently it won’t be too long until I reach the Medicare coverage gap when the price then will go up. I decided to bite the bullet and try paying for this insulin at least for a while as it made my blood sugars so much more stable than they had been on nova log. Eventually FDA will approve it for use in an insulin pump and I would then be able to go back to my 100% coverage under Medicare part B.