Medicare and Insulin Pumps

Because I am on disability, I am also on Medicare.  I have a Medicare supplemental plan and they follow Medicare guidelines.  Prior to getting the pump, I had to get a C-peptide test to show that I was not producing insulin.  I am coming up on my 27 year anniversary in January and I have no idea if I ever had a C-peptide done back in the early days, but I had to have one in order to get the pump.  I am not sure if you want to say that I passed or flunked since I only had a trace amount of insulin being produced, but I was able to get my pump.

I knew from seeing other people mention it on message boards that I would not be able to get my insulin thru just any pharmacy.  I checked with my insurance company to find out where I could get the insulin.  That was a fun process spending hours on the phone trying to find someplace.  My plan would only allow me to use a DME provider and they also had to accept Medicare.  The customer service reps at my insurance also called a lot of their suppliers – I knew some of the names that they gave me did not carry insulin, but I called them anyway so I could call my insurance back and say, these did not have insulin.  We finally found a pharmacy that just started taking Medicare and just became a DME provider with my insurance.  Now I could actually use the pump!  When I talked to the pharmacy, they said that they needed to get a copy of my C-peptide from my doctor.  I thought that was odd and thought maybe since they were new at this, just misunderstood what they needed but I wasn’t going to argue about it.  The pharmacist told me that their billing person was reading thru all the stuff that she had to do so I knew she was not familiar with the process.

Because of the problems I was having with CCS, I decided to switch suppliers for my pump supplies.  The pharmacy worked with ICU Medical to set up and account with them and get the Orbit Micros for me.  ICU Medical also gave them the name of a distributor that they would be able to get the Animas cartridges for me.  To make sure that I had enough infusion sets, ICU Medical also sent me another box of the Orbit Micros.  I will be able to get supplies from the pharmacy going forward, but the pharmacist said that I should order some to make sure I did not run out.  I had to order some cartridges from another supply company.

When I called a supply company that carries the Animas Ping cartridges, they said that they would need to get a copy of the C-peptide test from my doctor before they shipped any supplies out.  I know Medicare made several changes beginning in April so I don’t know if this is a new policy or an old one since I did not have a pump before.  The supply company did send a form requesting the C-peptide to my doctor’s office – the doctor has a new nurse and she called me about it so I know the supply company asked for it.

I have seen Type 2’s asking if they would be able to at least get supplies thru Medicare for the pumps they currently have.  I now know that answer is no unless your C-peptide meets Medicare guidelines.  I would also suggest any Type 1s that do not know if they ever had a C-peptide make sure that they have one before retiring so they don’t have an interruption in pump supplies.  The Medicare guidelines call for that C-peptide to be done fasting so you need to have a fasting BS at the same time.

Another change that was made effective April 1st is that you have to see the doctor that prescribes your pump stuff every 90 days.  A lot of endorks are busy and have a wait to get in.  I read on one of the message boards about a woman with a Minimed pump and she was asked the date of her last appointment when she went to order her supplies.  Her supply order was placed on hold because she had not been to her doctor within 90 days and they would not ship it until after she saw her doctor.  That is going to be the one rule that can be tough for me, especially having to travel so far in the winter.

I do understand if Medicare will only pay for a pump under certain conditions they would not pay for the supplies either if you don’t meet those same conditions.  I know that they are trying to cut down on fraud and although it can be inconvenient at times, I do understand why they would need to have a copy of the C-peptide for someone to order supplies.  However, I don’t see why it is necessary to see your doctor that signs the script for the pump every 90 days.  I know some people need those visits, but not everyone does.  That ruling seems like it will cost more money in the long run than save money.  But that is just my personal opinion!
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Comments

  1. Hi,

    Dealing with insurance can be tiring and exasperating – as tho dealing with diabetes was not enough.

    I am type 2 but in 2008 quaified for insulin pump and supplies under medicare with secondary paying balance. Some time in 2009 medicare apparently changed their requirements and no longer will pay for the supplies. They had me go for a c-peptide with blood sugar from same draw. I slightly missed qualifying. Now the secondary that said they would pay if medicare did not pay have denied the supplies claim. Guess it is back to the needle with a1c of 9-10 rather than the 6-7 control I was getting with the pump. I really hate that medicare pretends to CARE while denying us care that will prevent blindness/amputation/other severe complications to end in earlier death.

  2. karen Pickett says:

    i just went on Medicare and have been pumping for 10 years/type 1 for 35 yrs. I “passed” the peptide test, but cannot figure out the Medicare maze for supplies and insulin. New wrinkle is MC won’t cover Humalog. Is there a formulary for MC and how does the competitive bidding DME provider thing work. I live in north(read)r rural Florida. I am the only adult pumper served the the local pharmacies.

    • Karen, it is one huge maze! I can’t find anyone else saying that Medicare itself won’t cover Humalog. With the competitive bidding, you can only use the providers that Medicare says you can use and they are very limited.

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