Afraid of Medicare

My classic and now Dash pods only cost me $40 for a 3 month supply under Part D. The cost really varies to what Part D plan you have. In my case my husbands past employer supplies a Part D plan with Optum Rx that has been wonderful. It’s something you have to check into with the different plans coverage on what is important to you, how much it costs, and if it’s even covered.

It’s not perfect, but that is pretty easily done on the medicare.gov website

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Unfortunately medicare.gov does not have prices for OmniPod. Therefore it is tedious to find the best plan for OmniPod users.

Actually “advantage” refers to benefitting private (and especially the for profits) insurance companies. ADvantage plans promise alot - to policy holders and the govt. Supposedly they provide the coverage/service and bill traditional Medicare. Turns uot most advantage plans overcharge the govt (which does no one any good) and over use prior authorizations (like periodically having to prove that you “still have T1D” and are quick to deny claims. We are planning on traditional medicare with a supplement and an Rx plan. More and more reports are showing that hospitals and providers are trying exit the advantage networks (another issue - advantage plans drop providers with no advance notification to policy holders. I’m rather disappointed that AARP is a shill for United Health Care Advantage plans.
One thing that would be a bother to me about traditional medicare is the required in-office appts every 3 months. Most of my Endo appts are telephone over the past several years. My Endo knows I only need his help getting Rx’s. From what I understand pumps are covered (I think insulin for use ina pump is covered under DME - or maybe pumps are covered under pharmacy - don’t know for sure- but look into it)

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That rule does not apply to Omnipod pump or the insulin for pods, because they are covered via Part D pharmacy coverage. The CGM coverage is Part B + supplement and only requires doctor notes every 6 months.

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If you have a pump (except Omnipod) Medicare requires visit within every 90 Days (Not 3 months).
If you are Omnipod and/or MDI Medicare requires visit within every 180 Days (Not 6 months)

If your visits exceed those Day limits by even one day, you will not be able to get supplies until your supplier receives your doctor notes. I am MDI and did once have my visit on day 182 (within 6 months) and that delayed my insulin and CGM by about 1 week until all got straightened out.

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I’m almost 70 and have Medicare & Plan F Supplement (which pays 100% of anything) and love it. I pay nothing for my pump, pump supplies, insulin, lab, and doctors bills. I get a new pump later this year and it will cost me nothing. Deciding if the T-Slim X3 will be out or I should wait for it.

I had cancer surgery 18 months ago with a robotic laser and the bill was $100,000 and I paid nothing.

Be very careful of Part C Medicare Advantage Plans, they are made for only 1 thing and that is for big profits for insurance companies.

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I would like to say that not all Medicare Part C plans are the same. I have one that is a retirement benefit from Verizon. Premiums are low and surgery co-pay was very low. The ones I hear being touted in ads are probably scams.

I have the same experience as you Luis3.

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This was the scariest part for me, as I was dx’d in 1983 and never had any of this stuff done. When I finally did get a c-pep a few years ago it wasn’t according to the protocol (fasting etc) and came up low end of normal. Like a lot of us I still produce a bit of endogenous insulin, particularly in late afternoon, which is when I had the blood work done. So I was HUGELY anxious about this. Forty years struggling with T1 and now I gotta PROVE it??? FFS! And is there any recourse? Nope. So I bit the bullet, had the test done again, this time following protocol, and it was way below normal range. Phew. But the whole experience is demeaning in the extreme.

You can at least be reassured about that. Once you’re through the gate that’s it, you’re done.

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Just to let you know how well Medicare does things at least for me. They paid $700,000 in 2019, $150,000 in 2020, $750,000 in 2021, and $150,000 in 2022. Right now I am laying in a hospital and my bill has just exceeded $15,000. I have had to pay nothing to receive all of these services for me. Medicare is a must not an option.

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Same for the ACA; I did something rather silly involving a pair of skis and a tree a while back. It was under $100,000 but I paid exactly what I would have paid without the tree love-affair because I max out my payments.

Prior to the ACA my max was around $35,000/year and when my insurance company had paid $2,000,000 (a very real possibility in the US, as your numbers demonstrate) I was out on the streets (literally; medical bankruptcy was the leading cause of chapter 7 bankruptcy in the US prior to the ACA).

BTW, that $2,000,000 is a LIFETIME maximum the insurance would pay, not per year.

I agree that you should not at all be afraid of Medicare. As others have said, do NOT get an Advantage plan, find out what Part D will work the best for you, and get a good supplemental insurance to help cover the 20% costs of things that Medicare will not cover.

I disagree that OmniPod has to be expensive. I have a traditional Medicare plan and AARP-United Healthcare/ Medicare RX. I also have Physician’s Mutual as a supplementary insurance, and since I paid a high deductible for the first three years I was on their plan, I now have NO co-pays.

With that combination of plans, my Dexcom G6 supplies are free and my OmniPod 5 sensors cost me a total of $141.00 for a THREE-month supply. You just have to get the right plans in place, and you will have no problems getting things covered.

Be aware that Insulet Corporation has a Medicare Advisory Department, so if you call them, they should be able to answer some of your questions. If you choose the OmniPod 5, be aware that you will have to use the G6 CGM for now… they are soon to, but have not yet, totally switched the OM5 to work with the G7. That’s fine with me. The G6 and the OM5 work well for me.

You will be fine. Medicare is no more of a hassle than any other insurance, and you may find that you have even less costs than you currently have through your private insurance.

Hugs and good luck!

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@SherryAnn, I am also using AARP RX.
For the first OmniPod Dash 3-month supply I paid $126.
For the second OmniPod Dash 3-month supply I paid $407.15.
For the third and forth OmniPod Dash 3-month supply I will pay $663.66 each.
The copay goes up thanks to the donut hole.

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I’ve had type 1 for 50 years, am 73 now and became eligible for Medicare in 2016. At that time, we went for a UHC Medicare Advantage plan and in hindsight, should have gone with original Medicare with a Part D prescription plan. In 2023 I switched to original Medicare with Supplement N. Part B of Medicare totally pays for my 780G Medtronic pump supplies and its CGM. I have had problems convincing the home delivery pharmacy that insulin is to be billed to the durable medical equipment coverage in Part B, not Part D which is for other prescriptions. Medicare considers insulin a “supply” used in the pump, and the pump won’t work if it doesn’t have insulin. Medicare pays 80%; the 20% balance is paid by Supplement N.
When I had the Medicare Advantage plan insulin was paid as a prescription. The last year I had the MA plan, I paid out of pocket well over $2,200 that year for insulin. Advantage plans are coming under scrutiny, for one reason it is not really “Medicare” – it’s private insurance. And because of that, it’s a profit making corporation that considers its stockholders over patient care.

Yes, Helmut, we all end up paying more once we fall into the donut hole, and there is nothing we can do about that. I will tell you that with my old insurance, I was paying hundreds of dollars more for my Pods before the donut hole, and I paid over $1200 for three months once I got into the donut hole. So while $663 still is outrageous, I will pay less with AARP RX than with my old Caremark account. I put money away each month just to make sure that I have a healthy “healthcare” balance for when I need to use it.

I really don’t mind seeing my endo every 3 months. I like my doctors and their PAs, and they’re easy to talk to. I consider it a small price to pay, as it were, for all that original Medicare and my supplement cover for my diabetes care. My former endo did tell me once, however, that if it weren’t for Medicare, she would only see me once a year. Don’t think I would want to wait that long. :wink:

@SherryAnn, I am very happy with the OmniPod coverage so far. I hope that insurance companies will continue to cover OmniPods going forward when OOP will be limited to $2k.

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?? I had not heard about this. Is Medicare Part D planning to limit annual OOP to $2k? Is there an announced start date?

I’ve thought about changing from Omnipod to a DME pump such as Tandem, mainly to enjoy the better coverage and reduced OOP expense of pumping via Part B+Supplement. The cost benefit would change if the Part D OOP is limited.

@John58,
I just googled 2025 medicare part d changes:

“Millions of People with Medicare Will Benefit from the New Out-of-Pocket Drug Spending Cap Over Time. In 2025, Medicare beneficiaries will pay no more than $2,000 out of pocket for prescription drugs covered under Part D, Medicare’s outpatient drug benefit.”

I had learned about this change last year when I was preparing for my switch to Medicare.

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