I am a insulin pump user using one of Medtronic insulin pumps now for several years. I recently switched to a new UNC new Health plan designed for people with chronic illnesses. I was told at that time that I could 1. Get Lispro, the generic form of Humalog, and 2. My copay would be ZERO. Several people told me the same thing. Only after I tried to fill my RX at Walgreen – their preferred Pharmacy that they told me my co-pay would be $265. Their Mail order pharmacy would not even fill it! After 3 days of going round-and round here is what (UNC told me ). They said because my medical history showed I was using insulin in the pump it had to be billed under Part B – NOT D – and even if they tried to enter it as Part D – it immediately switched it to Part B. They said “They have to follow Medicare guidelines, and Medicare itself stipulates that insulin if used in a pump must be billed that way, and that my co-pay instead of being zero would be 20% of the negotiated price (over $250). My testing supplies and infusion kits are still zero co-pay. Can you PLEASE enlighten me on what is going on here? From the posts I’ve read it seems that I should pay Zero co-pay under Part B.
@sfriedman451 Hi Steven and welcome to the TypeOneNation Forum!
In my very humble opinion, Walgreens is absolutely useless when it comes to filling insulin prescription for pump users under Medicare.
UNC has been telling me for years that when billed under Part B, my cost should be zero - even when using Humalog and Novolog. A couple of times, my insulin prescription was properly filled properly, only to be bolled months later by Walgreens headquarters for hundreds of dollars.
Any ideas. Would a different pharmacy help?
Dennis - you seem to understand this better from reading your posts. My head is still swimming.Can someone PLEASE clarify this for me! I am an insulin pump user and use about 90U of insulin a day. I am on a Medicare Advantage HMO plan. I specifically signed up for this “New plan” that was designed for people with chronic conditions such as Diabetes. When I went thru the plan and my meds they told me that by changing to Lispro (generic Humalog) it would be classed as a tier 2 drug and annual costs would be about $300 or even zero. But this was under Part D. I then find out that as pump user it can ONLY be billed under Part B. My monthly co-pay is $265. The Insurance company after nearly 2 days of phone calls between them and Walgreens tells me it has to be Part B because they are following Medicare Guidelines. Sure enuff – when I read those guidelines it says that. So explain to me. My infusions sets, testing supplies, reservoirs for me pump are all free under part B. But my insulin is priced at 20% of the inflated list price. While it’s true I have no donut hole, paying the amount under Part B is going to break me. Many people say they have straight Medicare and then but a Medicare Part C policy to cover additional costs and pat zero. This is not available to me with my current plan. Yet others have told me they don’t have Medicare Part C but still pay zero. And why in the name of heaven would supplies be at no charge, but the very same insulin is prices 200 or more times the price under Part B vs. Part D. Do have I this right because I have been told so many different stories now from everyone.
Steven @sfriedman451, sounds as if we are using similar insurance plans; I have Advantage Choice PPO underwritten by UHC. Since Insulin Lispro was released, it has been a Tier 3 even though it is “generic”; I just checked the latest formulary, dated March 252020, and it is still classified as Tier 3 - requiring co-pay.
Has anyone had any experience with RX solutions? I was looking for an assistance program to help with covering the cost of my insulin. They say they can ship directly from the mfg. for $49 per month (Qty whatever the MD Rx’s) plus a one time $60 enrollment. It sounds very good - too good. Any takes on this? https://rxsolution.net/