This is a guest post, reprinted in its entirety with permission of the author, Yerachmiel Bruchya HaLevi Altman.
FIRST STEP IS GO TO PHARMACY AND SEE IF THEY ARE MEDICARE PROVIDER for Durable Medical Equipment (DME).
IF SO – ask if they have the forms needed for insulin as DME when using a pump. If they say this is NOT the case show them the info in the included booklets or what I’ve got below (best from Medicare book as they cannot say it doesn’t exist). THEY should have the form you need (I’ll see what forms I’ve got at home, but that is the best and easiest way).
[You] NEED TO GET prescription from doctor outlining #units/day and used in pump (can also say x vials of insulin/month but MUST have insulin/day as well – and the numbers better work correctly). Your best bet is figure out your monthly need, increase by one (in case of illness, etc) and then multiply number of bottles by 1000 (10 cc/bottle * 100 unit/cc) / 31. This will provide the number you need to have as daily dose! Don’t forget how much is lost in tubing and thrown out when changing sets, which is why you use the monthly number of vials not the pump’s report of what you use.
You must download, fill out and have your doctor finish filling out CMS10125 which is the form authorizing the insulin as a DME expense. There are other pieces of information needed (date went on pump, serial number of pump, etc) but these are straightforward and easy to obtain or get from records.
Please look at page: https://www.medicare.gov/coverage/durable-medical-equipment-coverage.html and print out what you think appropriate if the company or pharmacy isn’t helpful. Do you need to change pharmacy? Might be worth getting at local Walgreens or similar (Walgreens and CVS both advertise the Medicare part B insulin).
Medicare will only cover your DME if your doctors and DME suppliers are enrolled in Medicare. Doctors and suppliers have to meet strict standards to enroll and stay enrolled in Medicare. If your doctors or suppliers aren’t enrolled, Medicare won’t pay the claims submitted by them.
It’s also important to ask your suppliers if they participate in Medicare before you get DME. If suppliers are participating suppliers, they must accept assignment. If suppliers are enrolled in Medicare but aren’t “participating,” they may choose not to accept assignment. If suppliers don’t accept assignment, there’s no limit on the amount they can charge you.
Infusion pumps & supplies
How often is it covered?
Medicare Part B (Medical Insurance) covers infusion pumps (and some medicines used in infusion pumps if considered reasonable and necessary). These are covered as durable medical equipment (DME) that your doctor prescribes for use in your home.
All people with Part B are covered.
29 — Section 2: Medicare Part B-Covered Diabetes Supplies
Insulin pumps worn outside the body (external), including the insulin used with the pump, may be covered for some people with Medicare Part B who have diabetes and who meet certain conditions. Insulin pumps are considered durable medical equipment. “Durable medical equipment” is certain medical equipment ordered by your doctor for use in the home. How do I get an insulin pump? If you need to use an insulin pump, your doctor will prescribe it for you. Note: In Original Medicare, you pay 20% of the Medicare-approved amount after the yearly Part B deductible. Medicare will pay 80% of the cost of the insulin and the insulin pump. For more information about durable medical equipment and diabetes supplies, visit Medicare.gov [https://www.medicare.gov/], or call 1 800 633 – 4227. TTY users should call 1 877 486 – 2048.
Insulin Pumps and the Insulin Used in the Pumps
Insulin pumps worn outside the body (external), including the insulin used with the pump, may be covered for some people with Medicare Part B who have diabetes and who meet certain conditions. If a beneficiary needs to use an insulin pump, their doctor will need to prescribe it. In the Original Medicare Plan, the beneficiary pays 20% of the Medicare-approved amount after the yearly Part B deductible. Medicare will pay 80% of the cost of the insulin pump. Medicare will also pay for the insulin that is used with the insulin pump. Medicare Part B covers the cost of insulin pumps and the insulin used in the pumps. However, if the beneficiary injects their insulin with a needle (syringe), Medicare Part B does not cover the cost of the insulin, but the Medicare prescription drug benefit (Part D) covers the insulin and the supplies necessary to inject it. This includes syringes, needles, alcohol swabs and gauze. The Medicare Part D plan will cover the insulin and any other medications to treat diabetes at home as long as the beneficiary is on the Medicare Part D plan’s formulary. Coverage for diabetes-related durable medical equipment (DME) is provided as a Medicare Part B benefit. The Medicare Part B deductible and coinsurance or copayment applies after the yearly Medicare part B deductible has been met. In the Original Medicare Plan, Medicare covers 80% of the Medicare-approved amount (after the beneficiary meets their annual Medicare Part B deductible of $131 in 2007), and the beneficiary pays 20% of the total payment amount (after the annual Part B deductible of $131 in 2007). This amount can be higher if the beneficiary’s doctor does not accept assignment, and the beneficiary may have to pay the entire amount at the time of service. Medicare will then send the beneficiary its share of the charge.
Follow Yerachmiel Bruchya HaLevi Altman on Facebook and join the Bonnie’s World Facebook Group to read updates to this post. I also welcome your thoughts, suggestions, or feedback in the comments section below.