testing supplies - word to the wise.

[Ms. Toad]

Once again, I'm frustrated about running into mass ignorance about coverage for testing supplies - and pissed at my doctor and Walmart. I may as well pass on my knowledge.

The trigger this time was that my spouse's A1C is going up and up. She weighs about 110 soaking wet, but she has absolutely no clue what a carb is. She's about to start on Januvia, along with Jardiance - and her doctor told her she needed to start testing.

Despite a relatively thorough knowledge of Medicare on anything else we've had a conversation about, our doctor is apparently clueless that diabetic supplies are covered by Medicare. So he sent her off to Walmart to buy testing supplies, which they gladly sold her.

When my spouse got home, I was cranky with both her (she knows she doesn't understand Medicare/insurance/anything medical and needs to check before spending $$) and the doctor (who sent her to Walmart instead of handing her a prescription). But she assured me that they were returnable.

Walmart begs to differ. They didn't have a shelf tag which warned the supplies were excluded from their "nearly everything" return policy. The pharmacist who helped her didn't bother to mention this (although we were told that she should have), nor did the pharmacist ask her about the possibility of coverage under Medicare (despite the fact that she looks Medicare age). And it took me about 30 minutes to find and confirm that the store return policy actually does exclude diabetic supplies.

We got the requisite prescription from her doctor so that Walmart could file a claim with Medicare for the purchase so we could get a refund from Medicare for the supplies already purchased - which is how Medicare works if the provider requires payment up front. They have flat out (in violation of their contract with Medicare) refused to file the claim. For most anything else, if a provider flat out refuses to file a claim with Medicare, the patient can file a claim directly (that is one of the three reasons a patient can file a claim directly). Not so with diabetic supplies - so Walmart can apparently refuse to file the claim all they want and there is nothing I can do about it.

So we are out $45 paid for stuff we were entitled to for free. Small potatoes in the grand scheme - but this kind of insurance crap that goes on because no one challenges it reminded me of all the other diabetic supplies confusion I've encountered in the past.

So - in case you don't know:

Unlike nearly everything else - Walmart will not accept the return of unopened diabetic testing supplies. Even if there is a reason that sealed packages of strips might have been damaged by the customer by putting them someplace hot/damp, there is zippo chance that the meter (sealed in its box) and the lancets (sealed in their box) could have been damaged by the customer - especially not in two days.

If you are covered by Medicare and your doctor believes you need to test your blood glucose, you are entitled to diabetic testing supplies under Part B - up to 100 tests a month, more if your doctor believes you need more. (That means 80% coverage if you don't have a Medigap plan, and some portion covered by your Medigap plan if you have one). I don't know about Medicare Advantage plans - but it ought to be covered by the medical portion of the plan, not the prescription portion. You need a more detailed prescription than usual (there are 5 things that need to be included: Whether you have diabetes. What kind of blood sugar monitor you need and why you need it. (If you need a special monitor because of vision problems, your doctor must explain that.) Whether you use insulin. How often you should test your blood sugar. How many test strips and lancets you need for one month.)

This experience reminded me of my long-ago insurance frustration (before Medicare): Diabetic supplies (glucose meter, test strips, lancets) are often covered by insurance in two different ways: prescription and DME. Coverage as a DME (durable medical device) is often far more comprehensive. (In most of my plans it was covered at 100% in contrast to prescription coverage which only covered about 20% of the cost. Typically you have to get them by mail order to be covered as DME.) The last place I worked had that arrangement - and I was the only person with diabetes I know of under the plan who was actually paying nothing for testing supplies, because everyone else was just taking the prescription to the pharamacy and they were processing it under the drug plan and charging an arm and a leg.

This disease is costly enough (especially on Januvia or Jardiance - can anyone say, "Hello donut hole!" ) - coverage for testing supplies needs to be much more clearly advertised so we're not throwing money in Walmart's corporate profit pocket.

[MOMFUDSKI]

1. I am a diabetic on insulin.

It is my understanding that one can't be charged for any diabetic supplies - test strips, meter, syringes, and insulin. The cost is paid by your insurance company but does add up toward you winding up in the donut hole. Work with your doc who should know how this works for people on Medicare. I have an Advantage Plan but it shouldn't matter what type of plan you are on. Sorry you spent some money but it won't happen again. Have a good nite.

[Ms. Toad]

2. That is probably specific to the MA plan.

Insulin is capped at $35 for at least one brand per insurance plan, by law. Whether they charge you that much is up to the drug part of your plan. And Jardiance and Januva are not capped. Each is about $500/month toward the donut hole. The first month each year eats up the deductible (around $500), then just for Jardiance - we hit the donut hole in September. But now that we've added Januvia to the mix we'll hit it in July (maybe earlier). It's gonna be an expensive year. I think she'll drop Jardiance. It is driving her nuts (constant yeast infections and a bladder that won't stop), but she just paid a bit over $500 for a 3-month prescription so she'll use that until her next check-up and if her A1C isn't too outrageous will probalby switch entirely to Januvia.

But back to the main quesiton - Diabetic supplies are covered by Medicare - but under part B, so they aren't included in the build to the donut hole. They are the standard 80/20 split for covered durable medical equipment (ours are covered 100% under out plan - but they could cost up to 20% under a different Medigap plan or MA plan).

It is the doctor I am mostly pissed at. It isn't the first time he's messed up on diabetic supplies - when I was first diagnosed we were on standard insurance. He said I could test if I wanted and gave me a meter with a few test strips then pointed me to Walmart. I don't expect him to know everything about every insurance plan, and knew enough about insurance to check in with them, so I didn't ever pay anything for diabetic supplies. But now that I'm on Medicare (which I do expect him to know more than the thousands of plans out there) - and after sending prescriptions for years to my DME provider - I do expect him to at least think about writing a prescription. If he had given my spouse a prescription, she would have brought it home to find the cheapest provider, rather than heading off to Walmart.

And Walmart - their policy is ridiculous, and on top of that, their refusal to file a claim with Medicare so we can get the coverage we are entitled to pisses me off.