Does anyone know how Omnipod is billed? It used to be Medicare didn’t cover it because it fell between the “devices” and “prescriptions” cracks, but Insulet did an end run by making it clearly a prescription item.
So at present the insulin (pre-Wyden I think) et al. cost depends on the precise billing requirement for Omnipods (I use O4, but O3 and O5 should be the same; O4 and O5 are identical mechanically, O3 is barely distinguishable to anyone but us.)
To people outside the US this conversation will sound utterly insane, or maybe inane, but it matters here; health care costs depend fundamentally on choices made by us. I don’t want to make the wrong one as I’m about to be eligible for healthcare.
@John_Bowler Medicare classes Omnipod as a prescription to be covered under Part D only, because it’s a patch pump. Omnipod is not trying to change that. Because of that, the insulin you use in it will fall under Part D too.
So you have to find a Part D plan that covers Omnipod. You might make sure that your insulin you prefer is also on that formulary.
I haven’t read all of these posts, but I have opinions about Medicare. My brother has Type 1 and I manage his healthcare. It’s not advantageous for someone with Diabetes to have an Advantage plan. It’s cheaper to have a supplement. Also, ask people about their experiences with different insurance plans
I don’t recommend Humana & Aetna. So far, Anthem has been the best.
I’m experiencing better coverage with regular Medicare and a Supplement plan. The Advantage plan I had covered my pump and CGM supplies under Part D which was wrong and I didn’t understand until a couple of years ago. I have a Medtronic 780 G pump and CGM and little out of pocket costs. I have had trouble getting the pharmacy to understand that insulin used in a pump is covered under part B also as durable medical equipment and not under part D, the prescription plan.
I have been on Medicare for about 10 years, parts A,B and D. After retirement my former company had a reasonably good supplement as a benefit. They changed to an Aetna Medicare Advantage Plan (part C).
This plan has been great, lower cost than the supplemental with excellent coverage, my CGM and pump supplies have been 100% covered. I have had 2 surgery while on this plan. The doctor visit co-pays are $10 for PCP and $25 for specialists. I have several of the latter now. Getting old ain’t for sissies!
The problem is that there are legion of plans, supplemental or Advantage… Trying to wade through them to find the best fit is a real hassle.
It would be great if Medicare parts A, B and D were all we need, but that’s not the way health care works in these United States of America.
But it beats how things for elderly people was before Medicare.
When I switched from the Advantage plan to original Medicare and Supplement, OptumRX refuses to fill my insulin order. Since I’m on a pump and insulin is billed under Part B, they told me that they don’t fill orders billed to Part B, only D, so I am forced to go to Walgreen’s every 90 days to pick up my order. I wasn’t aware there was a mail order place out there that would fill orders for insulin used in a pump. If I could find one, it sure would be more convenient.
I had the same situation. In fact, I paid thousands of dollars out of pocket for insulin when I had an MA plan. Now on original Medicare and a Supplement. AllianceRx is associated with Walgreens and has home delivery for 90 day insulin orders. I’ve used them for about 18 months now and it was an incredible hassle last year to get them to understand that insulin used in an infusion pump is billed as a supply for durable medical equipment under part B. But I’ve finally gotten them on the train.
I must be lucky with the Verizon retirement benefit Medicare Advantage plan we have. I’m not sure whether insulin for my pump is part B but it is much cheaper than the backup Lantus pens I get which are part D.
Insulin for a pump, is covered under Part B by Medicare as DME. But In a lot of cases, your Part B coverage is being administered by a different company than your Part D coverage. Pharmacy mail order companies aren’t generally set up to supply/bill Part B items. A lot of Advantage plans administer both Part B and D so they might. And what insulin your Part D plan covers can vary per company/plan, especially Advantage plans, under Medicare guidelines.
Actually, Medicare part B covers insulin if it’s for a pump. Part D is for regular prescriptions, so insulin would be covered there for MDI. In either case its cost is limited to $35 per month. If you are on traditional Medicare and have a gap plan, that plan might cover the $35/month cost, but that depends on the plan.
Omnipod as a patch pump is under Part D, so any insulin for it is Part D too. Insulet does not plan to change that as far as I know.
Medicare Part B will not cover test strips and a CGM at the same time. Although you can get your CGM under Part B, and in some plans you can get your test strips covered under Part D. That’s what I do. But I guess that can vary depending on your plan.
This is correct. Pump insulin is covered under part B but only for reusable pumps, and pods are not included in that. There has been discussion about having a controller makes it durable, but for now part B won’t cover pod insulin, but it will cover insulin for Medtronic and Tandem pumps.
It’s a scary world changing how we do things. I’m 6 years away from Medicare.
I have Kaiser Permanente insurance and I like it because it is predictable, but it’s also more limited to options for different types of insulin. I will likely use Kaiser as a Medicare plan, mostly because I am used to it, and I know how to navigate it, but then things will likely change over the next6 years so I have time
This is a terrific introduction and summary for anyone with very basic to no knowledge about how Medicare plans work. It should be a sticky somewhere in the forum header or easy to access as so many members have questions about the process and the various permutations and combinations.
He’s really good. When he gets worked up, his voice gets a little shrill and he has a god awful midwestern accent. But you gotta look past it because he’s great.
In my experience when I had an MA plan, it would be billed to the prescription benefit plan rather than to Part B which explicitly covers insulin used in a pump; the insulin is considered part of durable medical equipment. Because I quit the MA plan (the cost of insulin was in the end very high for a 90 day supply) and went back to original Medicare with a Supplement plan, I now pay zero out of pocket for insulin. The Supplement plan pays the balance. I feel that I was “cheated” by the MA plan for 6-7 years before I figured it out. The Supplement plan does increase every year but not at the rapid rate that insulin cost was increasing under the MA plan. Medicare and Supplement plans are very regulated unlike the MA plans which are not.
