Hi everyone. I rarely post on here, but i am so frustrated right now I could choke someone!
I have been on the same policy with BCBS for a few years. I had always gotten pods directly from Omnipod. Then BCBS got into a dispute with Omnipod last year. My last two shipments from Omnipod were never paid by insurance cause BCBS refused. So then I was told to start using a local supplier, which I have been doing since the beginning of this year.
Last week I went to get more pods, and the local supplier told me that BCBS has decided I no longer "qualify" to be on a pump (since some directive of theirs that goes back to the first of the year) because my A1C is below 7.0.
This is all extrememly frustrating but it gets worse! I will be on United Healthcare starting Sept 1, and they only deal directly with Omnipod.
Does anyone know, since I have a huge balance with Omnipod from last year, if they will still let me get pods?
Ugh, I'm very sorry. This doesn't make a lot of sense. Your A1C is below 7, but they... don't want it to stay there? I believe that on the statement of medical necessity there are a few different options, so maybe your doctor can make sure the right box is checked so that you can continue with the Pod? Something like the box labeled: Variations in the day-to-day schedule (work, mealtimes, activity level) prevent successful glycemic control with multiple daily injections?
Also, I'm with UHC, and they definitely do not let me order directly from Insulet; I have to go through a medical supplier (mail order, in my case).
BCBS and a few other insurance companies (along with Medicare) are trying their best to make the Omnipod a non-durable medical device. The only advice is to consider another pump, which stinks if you hate tubes like I do. Good news for folks like you, is that there are some prospects for tubeless pumps that are physically more like a durable medical device coming in the future. BCBS definately is among the worst, I'm on them right now and it's been a fight for a while to get them to cover. I hope it holds out long enough to give other options.
As far as Omnipods, another advice I could give is call Insulet and see if they'll allow you to go on a payment plan to keep you in good standing until United can cover you.
I, too am on BCBS of NC. They stopped covering my shipments from Insulet back last November. I got no notice from either BCBS or Insulet until after my last shipment from Insulet on Nov 11. I had to scramble in January to find another provider and, fortunately did. That was not the end, however. BCBS decided not to cover my last shipment on Nov 11, for $2200. I did not know about it at the time until I got a letter from Insulet billing saying I may get a check from BCBS directly to cover the insurance part of the bill. I finally got a check from BCBS last week, endorsed it, and sent it to Insulet. I still do not know about the copay portion. It was last year, so I cannot use FSA funds to cover it. I feel your pain!!!
Strange, I'm with UnitedHealthCare and they do NOT deal with OmniPod and I have to get my supplies through Edgepark.
I hope you get it all figured out. If BCBS paid for pods earlier in the year then suddenly stopped, that seems like something you could appeal, maybe your HR person can help get that figured out?
I have some subset of your experiences. I use the Oregon high risk pool (OMIP) but this is administered by BCBSO (Oregon). I was initially supplied direct by Insulet, late last year, then the dispute and my supplier is now Byram Healthcare.
Now my HbA1c is below 7, but I don't think they know that yet; it is, of course, below 7 because I'm using the Omnipod (it was over 8 before.)
It is a nightmare, I don't think it's getting better, I'm a cynical aging diabetic and I hate health insurance too; it's getting about the Magaret Thatcher level of hate and she is well above Hitler for me (something to do with personal experience.)
I think our only course of action is to vigourously point out that it works, and that the alternatives, including wacking flying tube pumps, do not.
Sorry, not much comfort. The street price for Omnipod with BSBSO is $275/box. I think one positive thing we need is for Insulet to agree to sell us Omnipod at the lowest price they sell to insurance companies, then we can get the little shytes out of the picture and do the math ourselves.
Yes, my doctor checked the variations box. I do have enormous variations of excercise, yesterday I lifted 30 90lb bags of cement the day before I didn't, etc and MDI is a disaster area for me, but MDI is, I think, roulette with Insulin and I don't think insurance companies should dictate treatment.
Really? Can you give a reference, it would really help me (financially). Despite my attempts to get BCBSO to classify Omnipod as a supply, *not* a durable medical device, they refused. I get supplies paid at 100%, durable medical devices are 70% after deductible.
I have BCBS and also United Healthcare. I get my pods through Liberty Medical (through the mail)- I did just get a bill from them for $322.00 but I called them to dispute it and they said to disregard it because it was paid.
OMG!!! We have BCBS and are trying to get two of our three diabetic sons on the Omnipod!! I'm hoping since we are part of the federal employee program ther's a difference between just a regular employer. It seems that everything ELSE is an exception for the federal employees maybe this will be, too! Maybe that just works for the ones in DC? My boys do NOT want tubes and I want better control for them! MDI is NOT working for them. We are trying to get them to take more responsability for their diabetes but telling them to "draw 4 units" so they have to stop what they're doing...well, it doesn't always happen!! I'll say, Did you give yourself your shot? "UUUMMMMM......" I don't remember...I don't think I did..."Please keep your fingers crossed that BCBS works with us!!!
One of the best things about pumps is that they remember what happened. It's actually impossible to remember an injection for more than a few minutes - we do so many of them that, as soon as the last one has gone from short term memory, it is forgotten. When I used MDI from time to time, maybe once a month, I would do an injection, put the insulin pen back and immediately have *no* memory of doing it. Fortunately I almost always did it, but the only way to find out was to wait for the blood sugar high.
I think this is just a hint of things to come. I had Blue Chip RI until January of this year, and the company switched to HMO Blue New England (Anthem). My $20 co-pay for a three month supply of Pods is now $345.00! Insulet bills my insurance company, and then bills me for the uncovered portion. If I weren't working a lot of OT, I would not be able to afford my supplies. Anthem is horrible!
Hi there. I am currently on Cigna insurance and am worried b/c next year my company is switching--we have a choice of either BCBS or United. Are you suggesting that United healthcare is better at covering Omnipod than BCBS? Sorry, not trying to hijack the post, but am super stressed about this! Thanks for any input. Sorry you are having this issue :(
If you have an open choice of the two companies then it is simply a matter of asking each company what their negotiated price is for a box of Omnipods and how the company will bill you; they will be able to tell you whether you have to meet a deductible before they start payment and, after that, what percentage you have to pay.
With some group policies the out of pocket maximum is quite low; this is why those policies cost so much (maybe $800 or more per month), in this case the cost of a years supply of Omnipods (about $3000) may cause you to invariably hit the out-of-pocket maximum, then the math gets a lot easier. The insurance company should be able to explain that too (my wife just has a conversation with BCBSO in which the representative actually managed to explain all this to her, so I think they are getting better!)
The bottom line is that because you are a diabetic on Omnipod, which is expensive compared to the low cost of MDI, the cost of the Omnipod is likely to be the controlling factor in what you pay. The insurance company can tell you in a few minutes what the total cost will be (premiums, deductible, co-pay) assuming you don't have any unexpected serious illness and you can then directly compare the two plans.
