An American insurance lament or the battle of the working poor

Diabetes Technology Insulin Pumps
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About me: I'm a 49 year old male who has been type 1 diabetic for a little over 30 years. I've seen treatment change over the years. Currently, I am using an Omnipod pump from Insulet Corp. I fear that I may have to go back to using pens due to the prohibitive cost of pumps. Prohibitive because of the way insurance companies view pumping in these times. I have worked all of my adult life and always carried health insurance that covered my diabetes supplies. New insulins and delivery systems were always covered as part of prescription costs. Now, the latest and greatest of delivery systems, the insulin pump, is being excluded from the average working man's coverage. So we are clear as to my definition of "working poor", I gross about 45k per year, but cannot afford annual deductibles.

As many of you who pump know, a pump gives excellent results and improves quality of living. It allows some of the spontaneity back into your life. It is more sanitary and allows your dignity/privacy when managing your disease in public. So, for me, I guess it's back to pens and breaking out "the works" before each meal. I use "the works" to refer to the satchel that I used to carry pens, pen needles, alcohol preps in. It's a slang term sometimes used by heroin users for their injection kit. I remember a time going to a restaurant with my wife. As we sat in the parking lot, with my kit spread out on the dashboard of my car, a knock on my car window startled me. I turned to see a police officer standing there with his hand on his weapon. Apparently, some other patron of the restaurant had seen my kit on the dashboard as they passed by and notified the near by officer of possible drug use taking place in the parking lot. That experience left a mark on me.

I don't know why I've taken the time to write this, or your time to read it, except perhaps to vent. With all of the wonderful advancements in medicine and treatment, remember they are not all for you. The insurance companies will see to it that doctors are no longer allowed to practice medicine according to Hippocrates, but according to insurance companies bottom line. In closing I will say, do the best you can and be well.

Best regards,

Rafael

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Does your insurance have a Durable Medical Equipment part to it? If so, can any of the Omni-pod system be considered DME?

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Do you have a choice in your insurance company? If you work in a place where there is an insurance cost, surely one company would cover pump and supplies. Like Mike said, durable medical equipment is usually covered and that would be the supplies. Your dr can surely write an appropriate needs letter for the pump and supplies.

I guess I am not sure if you are now paying for your supplies. It sounds like you are but, are you?
What kind of insurance do you have and have they denied pump or supplies coverage? Is it the Omnipod itself? Would they cover another type of pump? More info needed...

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Sorry, I meant "a place where there is an insurance CHOICE," not cost! We know there is a cost...

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Yes it does. The annual deductible for it is $1500, followed by a 70/30. Omnipod is considered DME.

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Insulin for the pump is covered under regular prescription benefits, which is nice. My former employer's plan didn't pay for insulin. They said it was covered but I had a 100% co-pay. How is that for fun with definitions? To be clear, that's 5 vials per month of Humalog for $35. Full retail at CVS that would cost $817. To answer your first question, there is no choice of insurance company.

They would cover another pump the same way as Omnipod, so it's not brand specific. See my reply to Mike above. They cover the pump as DME, for which there is an annual deductible. The deductible is the most difficult part at $1500 out of pocket.
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Rafael, I sympathize with your frustration... my deductible is almost as big as yours -- $1250 -- then an 80/20 coinsurance kicks in. I'm a 2-day podder, so I have to purchase 15 pods per month instead of 10. So, cost-wise, I'm in almost the exact same situation as you.

That said, I'm not nearly as resentful as you seem to be about this. This is my problem, not someone else's, so I expect it to have a cost in my life. Just like my eyeglasses (nearly $1000 every year or two). My employer doesn't offer vision insurance, like most employers. Yet, I don't feel resentful that others aren't paying for my vision correction -- again, it's my bad luck, no one else's.

The total cost of caring for my diabetes with the Omnipod and Dexcom G4 is enormous. I pay a fraction of it with the insurance I have, and judging by what plans and premiums are available post-ACA, I'm extremely happy with my small-employer plan that is on a one year additional lifeline because of delays by the president.

I'm terrified what I'm going to probably have to face next year when we will have to get on board with plans that are compliant with the act. I make too much money for a subsidy, but not enough to be "rich" by any meaningful standard. I'm expecting the premium for myu family of 4, ~$750/mo, to double, and the deductibles to also double, from $1250/individual, $2500/family. Also co-insurance dropping from 80/20 to 70/30.

I can't afford that increase (around $15k annual) -- not by a long shot -- so I'm expecting not to be able to continue on the pod and the CGM after next fall.

However, I don't blame insurance companies at all. Nor do I resent them making a profit. If they don't, they don't exist, and then I'm gonna have to pay for it all, 100%.

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Ahh, thanks for the reply. Of course, I neglected to think that your DME plan would be different than mine.

My only response to Dave below would drag this thread into a political discussion, and that won't help anyone.

FWIW, when I was on MDI and using a pen (and still today with a pump), I simply didn't care what anyone thought because nothing I was doing was illegal in any way, shape or form, and I needed to take the insulin to live.

While this sucks, is there another pump choice that would be less expensive? Is there no other avenue to come up with the deductible? etc?

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Rafael, if you are open to tubed pumps, you may want to compare maintenance costs. I don't have direct experience but have read in various posts that the pod costs more over time, due to higher supply costs.

And, hoping not to debate this but to express my own view. I do disagree with our system of allowing insurance companies to make very high profits off illness. I won't go further on that but see nothing wrong with expressing frustrations with unreasonably high costs, of anything.

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Hello Mike, and thanks for getting back. I've spent the afternoon working numbers with my wife. She is employed as a medical biller for a private practice for the last several years and has over 20 years experience as a biller with an outsourcing firm prior to that. Without her, I am lost when it comes to things medical insurance.

Although my situation is not ideal to me, it actually works out less expensive over time to continue using the Omnipod as opposed to insulin pens. However, because it is mid year, I may have to use pens until the new calendar year.

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Hello Dave. I don't resent a business from making money/profit. I do regret change for the worse, hence "lament".

I still think the problem is deeper than any presidential legislation. Being diabetic over 30 years has taught me a few things. One, I am the only one responsible for managing my disease. As a manager, I want the best, most effective tools I can afford. In my previous reply to Neil, I had mentioned a "catch 22" from a previous employer's insurance: covered but with a 100% co-pay. Do you have any clue as to what that means? I don't want anyone to hand me anything, least of all the government. I merely wish to earn it. My work ethic is just as strong as it ever was. I'm holding up my end of the "bargain". Why is it that you and I cannot continue with pump therapy? Before you say it's the president's ACA's fault, let us pick this part of the conversation up in three years when he is no longer in office. If things are not better for us by then, then there is another problem afoot.

I wish you well, Dave! Good luck and best of health!