What Insulin Is Covered By Medicare?
Insulin is covered under Part D for people with diabetes. Insulin is not covered under Part B. Most people with Medicare Advantage plans cover insulin under their plans, although there may be a deductible and/or annual out-of-pocket maximum. Many Medicare Advantage plans have an annual out-of-pocket maximum of $3,400. For examples of plans that cover insulin, visit www.medicare.gov.
How do I get my Medicare coverage for insulin?
To get coverage for insulin, provide your Medicare information to your doctor or pharmacist. This will help him or her fill out the necessary paperwork to submit to Medicare. This paperwork is called the Medicare Coverage Analysis and is included in the materials that come with your insulin.
If you are using a Medicare Advantage plan, your doctor or pharmacist is able to obtain your coverage information through the plan.
How do I know my insulin is covered?
Medicare will cover your insulin if it has a National Drug Code that begins with the following: JAN, JAU, JAN1, JAN2, JAN3, JAN4, JAN5, JAN6, JAN7, JAN8, JAN9, JAN10, JAN11, JAN12, JAN13, JAN14, JAN15, JAN16, JAN17, JAN18, or JAN19.
Why do I need to get approval from my doctor to use insulin?
If you are older than 65, you must get approval from your doctor to use insulin. This is required by Medicare. Your doctor can help you with this.
When is my doctor's approval needed to use insulin?
If you are older than 65, you must get approval from your doctor if you need to change your insulin or switch to a new brand of insulin. There are situations in which you do not need doctor's approval. If you need to change your dose or switch to a different brand of insulin, there are times when you do not need to wait until your next doctor's visit. You should discuss this with your doctor.
Is there a time frame for getting approval from my doctor?
Yes. Your doctor must approve your request to use insulin within 30 days of when you fill the prescription for the insulin. If your doctor does not approve your request within those 30 days, you can go back to your pharmacist to get your insulin.
What if I need to change my dose or brand of insulin?
If you need to change your dose or brand of insulin, you do not need to wait until your next doctor's visit. You should discuss this with your doctor. There is a process to follow so that you can get your insulin as soon as possible. You must:
Obtain your doctor's approval as soon as possible.
If you are using a Medicare Advantage plan, inform your doctor that you will be using a brand of insulin that is not in the list of drugs your plan covers.
Pay for the insulin with cash, a credit card, or a Medicare prescription drug card.
Fill out the Medicare Coverage Analysis form.
If I need to switch my brand of insulin, what should I do?
If you need to switch your brand of insulin, there are times when you do not need to wait until your next doctor's visit to get your insulin. You should discuss this with your doctor. If you need to switch to another brand of insulin, you must:
What if I have a question about my Medicare coverage?
If you have any questions about your coverage, please call the TTY number for the company that is covering your Part D or Medicare Advantage plan. This number should be on your statement each month.
The Medicare Coverage Analysis
The Medicare Coverage Analysis (MCA) form is used by your doctor and/or pharmacist to find out if Medicare will cover your prescription. The MCA form contains information you should give your doctor and/or pharmacist, as well as questions your doctor and/or pharmacist should ask you. This form is included in the materials that come with your insulin.
What information is on the MCA form?
The MCA form contains information that you should give your doctor and/or pharmacist. This includes:
Your date of birth
Your Social Security number
Your Medicare number
The diabetic supplies you usually use
The brand and dosage of insulin you are using
When you need to renew your prescription
The doctor's name who has prescribed your insulin
If you are using a Medicare Advantage plan, a list of the drugs you are already using.
What questions should my doctor and/or pharmacist ask me?
The MCA form also contains questions that your doctor and/or pharmacist should ask you. These include: