Suppliers for Medicare DME insulin

Until mid-summer I was receiving my 3 month supply of insulin for my pump through the Medicare DME program. I was using a local pharmacy. The pharmacist now states Medicare will only allow their pharmacy to issue a one month supply at a time. I often run short.

Neither my endocrinologist nor Medicare representatives have explained why this change has occurred. What is even more troubling, I haven’t been successful locating a mail order supplier or local pharmacy that can issue a three month supply at a time–exactly what my endocrinologist scripts.

I’m new to the forum and expect I am missing crucial information.

Hi @rsoktown and welcome to the forum. I’m not on Medicare but If various pharmacies are refusing to fill a 3 month supply it sounds like your plan’s formulary has changed. With open enrollment going on now or in the very near future, this might be a good time to check your alternatives - an insurance broker might be able to help if you’re not comfortable doing it on your own.

If you run short each month discuss your additional needs with your endo so they can change your prescription to cover them. They might order an additional bottle, or set your Rx to fill every 3 weeks instead of four (that sounds odd but mine did that a while ago).

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Thanks for your response. Since my insulin cost is covered under the DME program of Medicare, I need a supplier who is contracted through Medicare to provide a three month supply. I really don’t think I can switch out of Medicare into an Advantage plan and stay in their program.

Understood. I would suggest checking with customer service to see if their formulary has changed. I thought they only changes with the plan year but apparently they can change at any time. At least this way you’ll know if it’s the pharmacy or the plan so you can understand what to expect.

@rsoktown Welcome Ray to the JDRF TypeOneNation Community Forum.

You didn’t mention which type Medicare coverage you have for your prescription benefit. I have United HealthCare and receive my insulin directly from the UHC OptumRx who ships all my medication to cover 90+ days. Auto-refill assures that my medications arrived automatically well before needed.

If you want to stay with your current supplier, make certain that your doctor writes your prescription properly. For instance, my doctor’s order is PRN [as there isn’t any way to predict how much insulin I need today] and states the minimum volume of insulin to be included in each refill.

I get insulin for my pump shipped every 90 days from Advanced Diabetes Supply (Carlsbad, CA) covered under Medicare Part B. I couldn’t find a local [pharmacy that was willing to bill Medicare Part B.

I have original Medicare with HOP (Health Options Program) that covers part D prescriptions. Their mail order supplier is Optum Rx, but I was told they could not send 90 day supply since they aren’t contracted to bill Part B Medicare for the insulin. Since Medicare covers the cost through Part B funds, I don’t understand why any part D supplier can’t fill the order.

Thanks, Marty. I’ll give them a call to see if they can supply my insulin.

I’m not in medicare but with my plan local pharmacies can only dispense 30 days. For 90 days I have to use the mail order option though optumrx. If you are running out you should ask the Dr to write the prescription differently. If you are using 40 units a day and the doctor writes that on the prescription they will only give you 1 vial even though you would run out after 25 days. If the doctor gives a little less info like 2 vials = 1 month supply on the prescription they will honor it and you won’t run out…

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This recently happened to me as well. The fact of the matter is that Medicare still does allow 3 months supplies of insulin. The pharmacy I ran into this trouble with was Walgreens. Fortunately, in my particular case at least, they have updated their computer system, and I am once again getting my 3 month supply. That being said, knowledge levels of Medicare rules and regulations vary greatly between individual pharmacists, even in the same pharmacy…

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One additional comment I should add: I am covered under Part B Medicare since I am on an insulin pump. For people who are not on an insulin pump, Part D Medicare coverage is all there is to the best of my knowledge.

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All of the comments above are helpful and plan to incorporate these suggestions when I visit the doctor’s office this morning.

(The irony of our system is this: My local pharmacist stated I can go to a local pharmacy without a script and buy the insulin at full price. )

I’ve occasionally paid out of pocket for some eye drops I needed following cataract surgery. Maybe we had not exhausted all the channels (pre-auths etc) - I don’t recall - but I needed to use them daily, was out, and didn’t want to delay getting them - so I paid. My pharmacy did find some coupons, which helped.
At least it’s an option but ideally you shouldn’t have to do it. All the best at your visit!

It is just the pharmacy not wanting to figure 3 different prices because of the price change that took place July 1. It is just pure laziness. Medicare made no such rule because I got fed the same BS. So I switched pharmacies. They all are causing trouble and I have filed a complaint with my US Senator and my State. It is against Medicare rules and if enough of us complain, someone will do something about it. When they said that to me, and promptly called Medicare and they told me that Medicare has no rules other than 3 months is the most you can get. There is no limit on the number of vials. It only goes by what the prescription states. So they are in danger of a fine by Medicare or the State Board of Pharmacy but neither has the manpower to enforce it. We need to all complain. At the next pharmacy I went to, they had no issue. I am going to bet it was Walgreens.

Your endocrinologist can increase the prescription quantity.