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Based on your insurance benefits, are insulin pumps and CGMs covered under your pharmacy benefit, durable medical equipment (DME) benefit, a combination of those two, or some other benefit(s)?
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I live in Italy. Both pump and CGM are covered under our National Health System.
The difficulty I have understanding this question is indicative of the complexity of the American medical system. I am a rocket scientist. I figure things of great complexity out. But this, the healthcare system, is like one continuous episode of Abbott & Costello in “Who’s on First?”
Oh. I did figure out to check #2.
The only thing good about turning 65 was getting Medicare. Prior to that all of this was pretty much out of pocket. That plus a $7000 deductible. Private insurance for diabetics sucks
Here in Canada, at least in my province, the pump is covered by the provincial government. They also contribute a quarterly sum of money towards pump supplies. My group health insurance (through work) covers 90% of costs for the CGM, and for any difference in pump supply cost between what the province supplies and what I actually spend.
Pump supplies are covered but because I use Medtronic, a greedy money hungry company based in Ireland to avoid US taxes, my CGM is not. I have an age discrimination class action lawsuit in the works. They finally have admitted the only reason they refuse to negotiate with Medicare is the label on their CGMs needs to be changed. Since April 2021, Medicare has covered all CGMs but Medtronic refuses to submit the claims because they know the label is wrong.
Medicare covers my Libre under Part B (DME) and my Omnipod under Part D (Pharmacy). This makes no sense.
Bill, I use an Omnipod too and haves turned 65 and signing up for Medicare for the first time. So, I will have the same situation as you concerning both CGM and Omnipod. I’m curious as to which company(ies) you have Part B and Part D through.
Hi Bill. Also on Medicare. Omnipod is part D. Is affordable until I quickly hit the “donut hole”. Then would be 25% co pay. As I already posted going to try MDI for awhile. If gets too expensive may purchase from Canada. Last resort going back to tubed pump under Part B. No cost. My special Medicare advantage plan misrepresented coverage for diabetics.
I said OTHER because for me, ALL my CGM supplies are covered by Pharmacy benefits, and my Insulin Pump infusion sets are also covered by pharmacy benefits, but my Insulin Pump cartridges are covered only under my DME coverage.
Most screwy part of it is my pharmacy benefits insist that “absolutely no pump supplies are covered under pharmacy benefits” yet their list of pharmacy benefits covered items includes the infusion sets I use with my pump.
Pump supplies and CGM transmitter are DME, sensors are pharmacy benefit 🤷♂️
It’s not applicable in my case as I live in the UK where my insulin pump(s), CGMs, insulin, test strips, etc. are all covered by our NHS (National Health System), which is financed by all working people as part of their wage/salary deductions.
CIGNA keeps changing where stuff is covered, they lie, the vendors are incoherent and lie, everything’s covered somehow and they leave me without supplies.
No idea about the pump, since I don’t use one. CGM is DME, unfortunately.
I am not familiar with “DME”. My Aetna-Medicare plan covers all my pomp and CGM supplies.
It’s interesting to see all of the different answers to this question. Currently, I am on Medicare. My insulin pump and Continuous Glucose Measurements (CGM) are covered under Part B, Durable Medical Equipment (DME). My secondary, private insurance, covers the remainder of the cost. My insulin is covered under Part D (Pharmacy), which is covered by my secondary, private insurance. I used to get my blood test strips under Medicare Part B, plus my private insurance, then switched over to Part D. I am no longer eligible for blood test strips by Medicare because my CGM does not require blood tests. It is all very confusing.
I forgot to mention that there is a Medicare annual deductible. Plus, I pay a $55 copay for insulin each time I order.
I’m on Medicare and insulin for my Tslim pump is covered by Medicare part B, my Medicare supplement covers the other 20%. It’s confusing for the pharmacy and must be billed correctly to avoid any out of pocket cost.
We are getting ready to transition from a company that covers CGM under DME and pump (Omnipod) under pharmacy, to a company that covers both as pharmacy.
Medicare still does not consider Omnipod “a pump” saying it’s disposable. Insulet was able to get pharmacy coverage for the DASH, and my Tricare for Life pharmacy benefits covers a 90-day order for just one co-pay. Because Medicare doesn’t consider Omnipod a pump—my insulin must also be covered as Rx.
I have a Medicare Advantage plan. Pumps, pump supplies, CGM and test strips are all covered 100%. Don’t know how it’s billed and, truthfully, don’t care. Insulin copay of $35 per month.
May I ask how much you pay monthly for Medicare Advantage? I have to choose next year.
Supplies and equipment are supplied by the VA. If needed Medicare Advantage program provides mix of prescription and dme. (I believed that the pump is dme, not sure about cgm.)
My CGM supplies are considered “durable medical equipment” by UnitedHealthCare and must be ordered from their supplier, Byram, so they are covered 100%, but they can only be ordered ten before, which means when I use the last replacement, since they last 14 days. Nothing better happen to that last one like getting knocked off or I’ll have to go back to outdated strips. I don’t use a pump.
I’m not sure what you mean by “covered”. I am supposedly covered but due to deductibles every year I have to pay $500+ dollars when I order my first set of supplies. I guess that is considered covered? Covered to me is 100%.
Because I’m in a tubed pump with Medicare, my pump is dme as well as my insulin.
A combination that changes over the years – pump is always DME, but most supplies are ordered through mail order. Now, I am seeing them come out of pharmacy benefits. I hear Medicare covers them differently still.
I stepped off my former employer’s insurance where I had a $2000 deductible, and on to Medicare in August. I selected DME for pump supplies and CGM. However, I have not seen a bill from Minimed yet for my last order, the first time on Medicare. I have a Gap plan and It should cover the co payment for Medicare B. We’ll see.
The pump supplies and CGM are only covered if I reach my $6300 out of pocket.
“Other”. I’ve lived in three states before now, and my pump supplies were covered 100% by Medicare. Now, in California, with Kaiser, I am paying a copay for them and for insulin and test strips. Kaiser is an HMO, if that’s the reason. No one has been able to give me an answer.
DME covered under part B . Medicare pays 80% my Anthem plan F covers the rest no copay.
The whole DME/pharmacy question regarding pumps, insulin, and pens is ridiculous and shows how ludicrous the US systems is. No doubt it is “played” by big pharma to ring as much money from the government (Medicare/Medicare), insuarance, and people. It really needs fixing, by regulation since corporate greed gets in the way!
I think I answered it correctly. I have BCFEP.
My insurance has a diabetes co-pay. 90 days of infusion sets is a $30 co-pay. 90 days of sensors is $30. 90 days of reservoirs is $30. A brand new pump is $30. A new transmitter is $30. Insulin and test strips are each different co-pays. It gets very confusing.
I put other, as I’m covered with VA benefits, and they cover it all.
My Medtronic pump and insulin are covered under DME. I switched to omnipod and it is only covered under pharmacy. Getting too expensive. Going to try MDI. Have tubed pump burnout. Insulin pens expensive. May end up going back to tubed pump. Why is insulin so expensive? So wrong.
DME for both CGM and Pump. My pharmacy benefit’s formulary shows the CGM as covered, but I could not get them to fill the prescription. I requested it from DME coverage along with the pump and pump supplies.
I don’t know what they are covered under. I used to receive them via Byram, then the company, now the pharmacy. I have been using my current pump too long to see a claim, but all others I think would be pharmacy.
I now only use Byram for colostomy supplies as you cannot find them anywhere besides medical equipment/supplies.