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7% Saline Prescription and Medicare Part B payment quandry
My husband is 81, diagnosed with MAC, and has been on the 3-drug regimen for 2.5 weeks. He uses a nebulizer 2XDay with 7% saline.
Problem: Humana won't cover the saline prescription because they say it is covered under Medicare Part B. But, when filling the saline prescription the pharmacist can't get Medicare Part B to work. Our secondary (not supplemental) health insurance Blue Cross/Blue Shield says (thinks?) it needs to be coded as a durable medical, which neither CVS nor Medicap will use. (It seems to me that while the nebulizer is a durable medical; the saline is more a prescription.) In the meantime, we are paying out-of-pocket for a saline prescription the pulmonologist and all others say should be covered under Medicare Part B. Anyone else had this experience? How was it resolved? Many thanks!
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Thanks, Sue. I am not familiar with CVS mail order pharmacy. Do you get your saline vials through them? Donna T
Even if you can get Medicare Part B to pay there is a 20% copay of around $8 so you will also have to have a Medigap policy that covers the copay to make all this trouble worthwhile.
https://www.walgreens.com/topic/pharmacy/nebulizer-services.jsp
Step 1 seems to be get this pari nebulizer from a walgreens that sells it in your area.
CVS is what is known as a Pharmacy Benefit Manager or PBM. (https://www.caremark.com/) I have access through my Medicare supplement insurer.
Yes, I do get my saline there sometimes - but I avoid it when possible because it is sent overnight in insulated containers, and that is a lot of packaging waste and shipping cost to be avoided - just drives up cost of care.
To anticipate the next question, I do not know if Caremark are available to the general public. But if you have health insurance with Medicare - either a Part B/Part D plan or an Advantage plan, you probably have a PBM. You need to look at the details of your plan.
Sue
I get mine from Amazon. They carry 3-7% saline for nebulizing by Base Labs (USA) for about $20 for 30 . I got frustrated with pharmacies and paying $64 a month !
I have Caremark but they refused to ship and said it wasn't covered under my plan. I filed an appeal and everything. Total waste!
To summarize options if you can't get Medicare to pay
1. Try Walgreens and if not available at your local Walgreens try one further away because they will ship for free via fedex . They will take the GoodRx coupon for a cost of around $10.28 for 60 vials.
2. Try CVS, Target, Walmart - there are good rx coupons for these stores also but cost in the neighborhood of $11 plus dollars.
3. Buy direct from a supplier for a cost of around $32.00 plus shipping costs.
4. You could try to get a prescription for a nebulizer from Walgreens and before
buying ask if they will also supply the sodium chloride and bill Medicare Part B.
I provided a link for this a few posts back.
Mona - I am amazed you got this to work! I just read through this whole thread again and am at a point where I am calling all the pharmacies in my area that supplies nebulizers. Can you share which pharmacy you ended up with that worked and whether it still does?
Thanks
Mary
Ditto, filed an appeal, nothing...Mayo clinic pharmacy says Medicare does not pay for sodium chloride and neither will my supplemental insurance...I'll try Walgreens per Sue
Hi Mary,
I phoned the small pharmacy I used to find out if they will ship saline. The can only if it is prescribed and shipped within Washington State.
My understanding when going through this challenge is for those of us on Medicare, I think the key is to find a pharmacy that can/will submit to Medicare Part B - DME coverage (DME - Durable Medical Equipment is the necessary piece). I found pharmacies that submit to Medicare Part B, but do not deal with DME. The pharmacy I used is housed in a specialty store that supplies nebulizers and other types of medical equipment, so they are familiar with and deal with DME insurance claims.
I hope my experience helps you to reach success with this dilemna as well.
Good Luck!