Insulin for a Pump – Medicare B or Medicare D?

PAAS National® analysts are frequently asked how insulin for a pump should be billed for Medicare eligible patients. Incorrect billing has caused very high dollar recoupments for some pharmacies. Be sure you know how to correctly bill your patients’ insulin.

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Insulin pumps currently fall under two categories, durable (tubed) or disposable (tubeless). Medicare coverage for insulin used in a pump will be determined by what type of pump the patient is using. Two examples of disposable or tubeless insulin pumps are the Omnipod® and the V-Go®. Because patients are required to discard and replace the insulin reservoirs, this categorizes them as disposable. Medicare Part D would cover insulin used in these types of insulin pumps.

Pharmacies must be mindful when dispensing insulin vials for Medicare eligible patients. Medicare Part D plans will not reject insulin claims, so you must monitor these closely. Not every prescription will state if it is used in a pump. Patients not receiving insulin syringes to use with insulin vials could indicate a pump is being used. PAAS recommends asking patients for confirmation of injecting or using in a pump prior to dispensing. See Billing the Correct Insulin for Use in a Pump in this month’s Newsline for types of insulin covered/not covered when used in a pump.

PAAS Tips:

  • When receiving a prescription for insulin vials PAAS recommends the following:
    • Identify if patient is Medicare eligible
    • Check if patient is injecting insulin, or if it is being used in a pump
    • Identify what type of insulin pump the patient is using, durable or disposable
      • If durable, was pump covered by Part B?
    • Self-audit prescriptions for insulin vials to ensure billing was done correctly
    • Contact PAAS National®® for additional questions regarding insulin for a pump
Dana Westberg, CPhT