I’ve been using Fiasp in my pump for the past 2 years and it’s been covered by Medicare part B. With the latest renewal CVS is saying Medicare rejected it because it’s no longer covered under part B. Which doesn’t really make sense since insulin for pump is considered DME.
Not exactly…I’ve never tried to go thru Part B for Fiasp because I use Omnipods. But I tried to find a Part D that covers both the Omnipod and Fiasp and could not find a plan. So I switched to Lyumjev for use in Omnipod and it seems to be equivalent to Fiasp, at least for me. The Lyumjev has a zero copay under the Cigna Part D plan I’ve been on this year and last but Fiasp is not covered.
I don’t use CVS for this but I know Walgreens has a dedicated manager for Medicare stuff. It was only when I got my doc in connection with that person that my Part B insulin problems finally got ironed out. Dunno if CVS has something similar.
I called Medicare and confirmed that Fiasp is indeed covered under part B. So then back to CVS and this time they tell me that Medicare says I’m not eligible for a 90 day refill until July 1. But they can refill a 30 day supply.
This really makes no sense since my last refill was in mid February, which is well over 90 days ago. If July 1 is the refill date then I should have had a refill on April 1. My best guess is that somehow Medicare got an April 1 date entered into their system. I’ve no idea if the screwup was on CVS or Medicare but at least I’ve got a refill to get me through to next month.
I have been fighting for insulin too. For some reason I can’t get but one vial at a time which lasts me about 20 days. Its an insurance thing, as I have called them. I’m going to get my dr. to change my prescription when I go next, if she will.
Medicare Part D coverage varies by state and by county in each state. The easiest is to go to Medicare.gov, input your zip code. Then add all of your prescription medications except for Omnipod which is not currently part of the Medicare.gov ecosystem. Then go to search 2024 Part D drug plans. Find a plan you like and then go to: Medicare | Insulin Pump Therapy | Omnipod
and see if the plan you like is listed on the Omnipod site. Even if it is not on the site, it is still worthwhile to contact the insurance company and ask if they cover Omnipod.
The order in which you go through these steps varies depending on various factors, such as if you have previously set yourself up on Medicare.gov so that you may have a few extra steps or you may have a few fewer steps if you have once used the .gov site as the .gov site saves previously entered information. This should be most if not all you need to find your answer or in the worst case, point you in the right direction.
Thanks! I pretty much followed your instructions, but I could not access any plan information from the Omnipod site. They ask for global information about coverage, doctor information etc, but no information about which plan offers coverage. (They want to contact my doctor, get a prescription, then contact me…)
Thanks, that was very helpful. One further question: Tier 3 is a percentage of the list price of the drop that the individual plans have negotiated. I believe it is not the same from plan to plan, so that the actual cost to the consumer would a depend on what the negotiated price is, the % I believe remains the same. Does that mean that each plan needs to be contact on the phone? Or perhaps I have this wrong. Does somebody know? I am learning so much trying to navigate this. I am on MDI but because of wide swings in my numbers, my endo wants me to try the Omnipod. I currently have a Wellcare Part D plan and when I called, their listed price for the Omnipod was about double the price that is given as list, so that the actual cost to me was about the market price as private pay.
@susan4 I have the Cigna Part D plan. It covers Omnipod 5 pods but with a high copay. Once I hit the donut hole I pay about $220+ for a 30 day refill of 15 pods. I have not checked in with all of the other listed plans but I suspect they are all high copays for pods in the coverage donut hole…there does not seem to be a way to avoid it.
I have become disappointed with Insulet for providing pods only as a pharmacy benefit, which really screws Medicare users. I’m hoping to switch to a Tandem Mobi pump next year because it will be covered as DME Part B.
I agree. Will look into the Tandem Mobi pump as it become available. But I really wanted the Omnipod as I am very active (cycling, hiking and xc skiing) and I am uncomfortable having devices/tubes attached to my belly. In addition, cycling shorts and xc ski gear don’t have pockets… one likely needs some carrying case, and anything around my belly is uncomfortable when on a bike. I know I am unusual, but I was really looking forward to trying the Omnipod, but it seems cost to me is prohibitive.
Many thanks to those who have responded to my query. If anyone knows a workaround to the very high copays needed for an Omnipod, please chime in.