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[IP] Re: (IP) Medicare Part B and insulin, Medicare Advantage plans and pharmacies



1.B To everyone who has issues with getting insulinB for a pump covered under
Part B if you're in a Medicare Advantage Plan, I did some research and the
answer is that Part C, Advantage Plans, must follow the same CMS rules for
what drugs are covered under Parts A, B or D as Original Medicare. First see
the link below for a CMS info sheet on the topic. I've quoted two sentences
from it.
https://www.cms.gov/outreach-and-education/outreach/partnerships/downloads/11
315-p.pdfFrom pg. 4 under Does Medicare Cover Drugs Under Part C? A: "A
Medicare Advantage Plan (Part C) must cover the drugs that are covered under
Part A and Part B."B From pg. 5 under Are There Certain Drugs that Part D
doesn't cover?B A: "B By law, Part D canbt pay for drugs when they would be
covered under Part A or Part B."
I emailedB our CA Medicare legal/regulatory expert to make sure my
interpretation of this is correct and she verifies that it is. So those of you
whose Advantage Plan is trying to bill your insulin as Part D, that is wrong
and is not allowed by CMS. Should you want it covered under Part B, you need
to complain. First start with the pharmacy. Whether or not it's under Original
Medicare or an MA plan, the pharmacy needs to put it through correctly as a
Part B item. Many don't do this correctly so that could be the source of your
problem. If they won't cooperate or sayB they're just followingB the plan's
rules, then escalate it with the MA plan. If the plan doesn't cooperate then
you can lodge a complaint with CMS by calling 1-800-Medicare.
However, per my prior responses on this topic, make sure you're really going
to be better off having it billed as Part B under your Advantage plan. As I
said, the MA plans in my area charge 20% for Part B drugs. You should find out
what your plan charges and compare that to the Part D copays including the
donut hole. It's easy enough to get it covered under Part D should you want it
to be by not having the prescription say it's for use in a pump. If you want
it covered by Part B the script must specify that. For those of you about to
start Medicare, carefully compare your overall costs under an Advantage Plan,
insulin being just one of them, to Original Medicare with a Medigap and
separate Part D plan. Under the latter option your 20% Part B coinsurance such
as for insulin in a pumpB would be paid for by the Medigap. Remember,
employer/union/retiree Medicare plans have their own rules.
2. To those of you who have had trouble with your pharmacy refusing to bill
Part B because they say they don't get reimbursed enough by Medicare, my
expert says you should notify CMS. While individual state governments have
jurisdiction over pharmacies rather than the feds, CMS still wants to know if
pharmacies aren't cooperating with the law on Part B billing and are refusing
to provide Medicare-covered prescriptions. Call Medicare and let them know.
You might also want to find your state pharmacy licensing/enforcement board
and see if it's legal for the pharmacies to do that.
I hope this helps.PamB 
B 
.
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