Does Medicare Cover the Cost of Insulin Pumps?

What kind of insulin pump does Medicare cover?

Medicare breaks insulin pumps into two main types: tubed and tubeless. The type of insulin pump you use will determine how much Medicare pays.

Medicare Part B

Medicare Part B is the portion of Medicare that covers a tubed insulin pump. Part B typically covers doctor’s office visits and durable medical equipment, such as wheelchairs or crutches. Medicare considers an insulin pump a piece of durable medical equipment.

You must meet certain requirements for a doctor to prescribe the pump. Examples of these requirements include:

• using insulin to control your diabetes
• requiring frequent adjustments and dosages to your insulin regimen
• needing to check your blood sugar at least four times a day

If you have Original Medicare (parts A and B), you’ll pay 20% of the Medicare-approved amount for the insulin pump. The Part B deductible applies. Medicare will pay the remaining 80% of the insulin pump’s cost.

Note, however, that Part B does cover the insulin you need to use with the pump, but it doesn’t cover insulin pens or supplies related to insulin, such as syringes, needles, alcohol swabs, or gauze.

Medicare Part D

Some people opt for a tubeless insulin pump instead. These are newer devices than tubed insulin pumps.

With a tubeless pump, you wear a patch that usually contains several hundred units of insulin. The patch typically works with a smart device to monitor blood sugar levels and deliver insulin.

Medicare Part D is the portion of Medicare responsible for covering tubeless insulin pumps.

Part D provides prescription drug coverage. You select a Medicare Part D plan from a private insurance company. Some plans cover tubeless insulin pumps, but not all do.

Part D plans have a list of covered medications called a formulary. Often, plans don’t include the tubeless insulin pump on their formulary. You’ll likely have to call your plan to find out if it covers the tubeless insulin pump.

In addition, note that under Part D, you can also get coverage for the insulin you need to use with a tubeless pump, as well as other supplies like gauze or alcohol swabs.

Medicare Advantage (Part C)

Medicare Part C, or Medicare Advantage, is an alternative to traditional Medicare. It’s when you receive your Medicare benefits through a private insurer that contracts with Medicare.

Medicare Advantage offers the same coverage as Original Medicare (Part A and B), and some plans also offer Part D coverage. Depending on your plan, your insulin pump may be covered.

Some Medicare Advantage plans, which vary by region, are also geared specifically toward those with a specific medical condition, such as diabetes.

It’s important to read a Medicare Advantage plan carefully before purchasing it in order to find out if it covers different types of insulin pumps and how much you might expect to pay.

Medigap

Medigap is a Medicare supplemental insurance policy for people with original Medicare. Medicare standardizes these policies.

If you choose to get a Medigap policy, it can help you pay for out-of-pocket costs related to the purchase of an insulin pump. Examples include coinsurance and copayments.

Some Medigap plans cover only a portion of these costs, whereas others cover the entire cost. It depends on the Medigap plan you choose.

How much does an insulin pump cost?

In a 2019 study of 241 adults with Medicare and type 1 diabetes who used insulin pumps, 24% described the cost of the insulin pump as a challenge. Another 29% cited the cost of insulin pump supplies as a challenge.

According to a 2017 study, yearly treatment with insulin pumps costs about $4,500, plus about $1,500 for supplies, such as:

• tubing
• infusion set
• batteries
• alcohol wipes

That said, insulin pump costs can vary by manufacturer and model. Some may have more expensive options, such as a touchscreen, waterproof casing, or a larger insulin reservoir. How much you pay out-of-pocket after Medicare kicks in is, therefore, going to vary.

How do you qualify for an insulin pump through Medicare?

If you have Medicare, getting your insulin pump covered depends on fulfilling at least one of the following:

1. You’ve completed a comprehensive diabetes education program and have been injecting insulin several times a day for at least 6 months, as well as checking your blood sugar at least four times a day for at least two months. Along with that, you meet one or more of the following criteria:
   • Your blood hemoglobin A1c (HbA1c) is greater than 7%.
   • You have a history of frequently low blood sugar.
   • Your morning fasting blood sugar levels exceed 200 milligrams per deciliter (mg/dl).
   • You have a history of severe fluctuations in blood sugar
2. You have type I diabetes, which is confirmed with a C-peptide level lower than 0.5, and have used an insulin pump before enrolling in Medicare, and have been checking your blood sugar at least four times per day for at least a month before enrollment.

To continue getting your pump covered by Medicare, you will need to see your treating doctor once every three months for follow-up visits.

Takeaway

If you require frequent insulin injections, you may wish to talk with your doctor about whether an insulin pump could help you. It may be covered by Part B or Part D, depending on the type.

Other related plans, such as Medicare Advantage or Medigap, can also help with coverage. That said, it’s important to contact Medicare to ensure your pump is from a Medicare-approved supplier.