Prescription Drug Plans

FAQ-Medicare and Insulin

Does Medicare cover injectable insulin?

Yes, it is covered under your Medicare Part D Prescription Drug Plan.

Are all types or brands of insulin covered by Medicare Part D?

No they are not. While Medicare Part D rules state all Medicare Part D Plans (regardless of whether it is a standalone Part D or part of your Medicare Advantage Plan) must cover at least two short acting, intermediate, and long lasting insulins, which insulins a Plan may have on their Formulary (list of covered medications) is the Part D Plan’s choice. If you fill an insulin which is not on the Plan’s Formulary, you will pay 100% of the cost. We provide each of our clients a link to their Part D Plan’s formulary, so you or your doctor can review it at any time. If you have further questions, please call or email HTA as our Policyholder Services team is always here to help.

What if I want to use an insulin which is not on my Part D Plan’s list of covered insulins (Formulary)?

Your doctor will need to file a Formulary Exception. While a Formulary Exception is not a guarantee of coverage, it does allow your medical provider to make an argument as to why you cannot take any other covered insulins. At HTA we are here to help and so for assistance with the Formulary exception process, please call or email HTA.

What is the cost of my injectable insulin?

Good news! Due to the Inflation Reduction Act which was signed into law on September 2022, for anyone who fills their insulins under Medicare Part D (regardless of whether it is a standalone Part D or part of your Medicare Advantage Plan), the cost will be $35 for a one month supply or $105 for a 90 day supply. In addition, you are not subject to any of the Medicare Part D deductible and those co-pays remain true until you hit your Catastrophic Stage, at which point the cost of your insulins will be 5% of the cost but not to exceed $35 for a one month supply. For more information on Medicare Part D Plan Stages, please visit our information webpage.

Where may I purchase my injectable insulins?

Where you may purchase your insulins depends upon your Medicare Part D Prescription Drug Plan’s network of pharmacies. It you use a pharmacy which is not in network then you will pay 100% of the cost. If you have further questions regarding your pharmacy network, please call or email HTA.

May I purchase my injectable insulin via a mail order pharmacy?

Yes! However, each Medicare Part D Prescription Drug Plan has a designated mail order pharmacy partner. Failure to use the designated mail order pharmacy partner may result in higher medication costs. When you enrolled in your Medicare Part D Prescription Drug Plan, the Plan sent you a welcome packet. Instructions on how to set up mail order either online or via phone was included. If you wish to discuss your pharmacy options further please call or email HTA.

Am I limited to a 30-day supply of my insulin?

No you are not. As long as your prescription is written for a 90 day supply, not expired, and the pharmacy has enough insulin in stock, they will provide the full 90 day supply.

Is prior authorization or step therapy required for my injectable insulin?

It is very rare any drug management technique, such as prior authorization or step therapy, is required for insulin. However, when in doubt you should refer to your Medicare Part D Plan’s Formulary for any limitations. If you have further questions, please call or email HTA.

What about my glucose monitor, my lancets, or my test strips?

All three are considered durable medical goods.

If you have Original Medicare and a Medicare Supplement Insurance Plan, you have coverage under Medicare Part B. Medicare Part B has an annual deductible, a 20% co-insurance, and possible excess charges. However, your Medicare Supplement Insurance Plan may cover some or all of these Medicare Part B costs. Please remember, you must see a Medicare participating supplier. For further questions, please review your Medicare Supplement Plan Insurance letter benefits here, or call or email HTA.
If you have a Medicare Advantage Plan, you may be limited to your brand choices and where you may purchase them. In addition, your costs for such supplies may differ according to your Plan’s benefits. We strongly encourage you reach out to your Medicare Advantage Plan so they may review such information with you regarding the purchase of your diabetic supplies.

Does Medicare cover continuous glucose monitors (CGM)?

Yes, both the monitors and it sensors are considered durable medical goods. CGMs are approved for use by those diagnosed with Type 1 or Type 2 diabetes and who are under the care of a medical professional. This means if you are pre-diabetic you do not have coverage for a CGM. In addition, Medicare requires the CGM prescription initially be written for both the monitor and the sensors (this is true even if you do not intend to use the monitor as many smart phones have apps).

If you have Original Medicare and a Medicare Supplement Insurance Plan, you have coverage under Medicare Part B. Medicare Part B has an annual deductible, a 20% co-insurance, and possible excess charges. However, your Medicare Supplement Insurance plan may cover some or all of these Medicare Part B costs. Please remember, you must see a Medicare participating supplier. For further questions, please review your Medicare Supplement Plan Insurance letter benefits here. Please know, we often find pharmacies have a hard time understanding how to properly file a claim for a CGM and its sensors. We encourage you call or email HTA so that our Policyholder Services team may provide you with some pointers to make the process hassle free for you.
If you have a Medicare Advantage Plan, you may be limited to your device choice as well as from where you may purchase it. In addition, prior authorization is often required and your cost for the device and its supplies may differ according to your Plan’s benefits. We strongly encourage you reach out to your Medicare Advantage Plan so they may review such information with you regarding the purchase of your device and/or supplies.

Does Medicare cover insulin pumps?

Yes, both the pumps and the insulin are considered durable medical goods.

If you have Original Medicare and a Medicare Supplement Insurance Plan, you have coverage under Medicare Part B. Medicare Part B has an annual deductible, a 20% co-insurance, and possible excess charges. However, your Medicare Supplement Insurance Plan may cover some or all of these Medicare Part B costs. Please remember, you must see a Medicare participating supplier. For further questions, please review your Medicare Supplement Plan Insurance letter benefits here, or call or email HTA.
If you have a Medicare Advantage Plan, you may be limited to your device choice as well as from where you may purchase it. In addition, prior authorization is often required and your cost for the device and its insulin may differ according to your Plan’s benefits. We strongly encourage you reach out to your Medicare Advantage Plan so they may review such information with you regarding the purchase of your device and its insulins.

Does Medicare cover Omnipod?

Yes, both Omnipod insulin delivery systems are covered under Medicare Part D. However, very few Medicare Part D Plans have the Omnipod on their list of covered medications, which is called a Formulary. This means your Medicare Part D Plan (regardless of whether it is a standalone Part D or part of your Medicare Advantage Plan) choice is extremely important. This is especially true as a Plan’s Formulary can change. We encourage you to reach out to HTA during the Annual Enrollment Period (10/15 through 12/07) so we may ensure your Part D Plan choice is appropriate for you. If you have further questions regarding the coverage of your Omnipod, please call or email HTA.

Does Medicare cover diabetic screenings?

Medicare abides by preventative services outline in the Affordable Care Act (ACA). The ACA follows American Medical Association in stating diabetic screening are appropriate for those with any of the following risk factors: a history of high blood sugar, obesity, hypertension, or history of abnormal cholesterol levels. In addition, a screening may be appropriate if you are age 65 or old and have a family history of diabetes or gestational diabetes.

If you have Original Medicare and a Medicare Supplement Insurance Plan, your services will be covered at 100%. Please remember, you must see a Medicare participating provider. For further questions, please call or email HTA.
If you have a Medicare Advantage Plan, your services will also be covered at 100%. However, you may be required to see an in network provider We strongly encourage you reach out to your Medicare Advantage Plan so they may review your options for diabetic screening.

I see my eye care provider for eye related diabetic issues. How is this covered?

Medicare covers diabetic related eye issues such as glaucoma, diabetic retinopathy, and diabetic eye screenings.

If you have Original Medicare and a Medicare Supplement Insurance Plan, you have coverage under Medicare Part B. Medicare Part B has an annual deductible, a 20% co-insurance, and possible excess charges. However, your Medicare Supplement Insurance Plan may cover some or all of these Medicare Part B costs. Please remember, you must see a Medicare participating provider. For further questions, please review your Medicare Supplement Plan Insurance letter benefits here, or call or email HTA.
If you have a Medicare Advantage Plan, your rules to receive diabetic eye care may differ. In addition, you may be required to see an in network provider and your costs for care may differ according to your Plan’s benefits. We strongly encourage you reach out to your Medicare Advantage Plan so they may review such information with you regarding diabetic eye care.

I see a podiatrist for foot related diabetic issues. How is this covered?

Medicare covers visits to a podiatrist for diabetic nerve damage in the foot and lower leg and amputation caused by diabetes. In addition, Medicare also covers therapeutic shoes and inserts for those with severe diabetic foot disease.

If you have Original Medicare and a Medicare Supplement Insurance Plan, you have coverage under Medicare Part B. Medicare Part B has an annual deductible, a 20% co-insurance, and possible excess charges. However, your Medicare Supplement Insurance Plan may cover some or all of these Medicare Part B costs. Please remember, you must see a Medicare participating provider. For further questions, please review your Medicare Supplement Plan Insurance letter benefits here, or call or email HTA.
If you have a Medicare Advantage Plan, your rules to receive diabetic foot care may differ. In addition, you may be required to see an in network provider and your costs for care may differ according to your Plan’s benefits. We strongly encourage you reach out to your Medicare Advantage Plan so they may review such information with you regarding diabetic foot care.

My doctor suggested nutritional training for those with diabetes. Do I have coverage for this?

Medicare abides by preventative services outlined in the Affordable Care Act (ACA). The ACA lists nutritional training for those diabetes as a preventive service which includes nutritional and lifestyle assessments, individual or group therapy nutritional services, and a review of contributing lifestyle factors. These services may only be performed by a registered dietician.

If you have Original Medicare and a Medicare Supplement Insurance Plan, your services will be covered at 100%. Please remember, you must see a Medicare participating provider. For further questions, please call or email HTA.
If you have a Medicare Advantage Plan, your services will also be covered at 100%. However, you may be required to see an in network provider We strongly encourage you reach out to your Medicare Advantage Plan so they may review your options for nutritional training.

I was recently diagnosed with diabetes and my doctor mentioned diabetes self-management training. What is this and do I have coverage under Medicare?

Diabetes self-management training teaches those diagnosed to cope with and manage their diabetes. This program may include up to 10, one hour sessions on such things as healthy eating tips, exercise, glucose monitoring, and other risk reduction actions. Inclusion in the program requires a written order from your medical provider and in most cases, are group sessions.

If you have Original Medicare and a Medicare Supplement Insurance Plan, you have coverage under Medicare Part B. Medicare Part B has an annual deductible, a 20% co-insurance, and possible excess charges. However, your Medicare Supplement Insurance Plan may cover some or all of these Medicare Part B costs. Please remember, you must see a Medicare participating provider. For further questions, please review your Medicare Supplement Plan Insurance letter benefits here, or call or email HTA.
If you have a Medicare Advantage Plan, your ability to access and the cost for a diabetes self-management training is dependent upon your Plan’s benefits. We strongly encourage you reach out to your Medicare Advantage Plan, so they may review your benefits.