Loss of insurance

I have United Healthcare (UHC) insurance and last year I started using the OmniPod system. I initially checked with UHC to verify that the PDM and associated pods would be covered. They were and UHC paid 90% of the costs (after I met my deductible). I recently contacted Diabetes Speciality Center (DSC) to place another 90-day order of pods and they indicated they would need to first verify the pods were covered so they could tell me what my cost would be. They left a phone message for me on Friday indicating UHC had denied coverage for the pods. I managed to get in touch with a UHC representative before the end of the day and when I related this info to him, he was a little shocked to hear the pods would not be covered. He put me on hold while he spoke with the department that makes those decisions and finally got back to me and confirmed the pods would not be covered. I informed him my benefits indicated that an insulin pump and associated supplies were covered, but he responded that the insurance also specified they would not be covered if a 'more cost-effective alternative' existed. I asked which pumps those might be and he would only provide their list of four 'approved' providers which were Animas, Medtronic, Roche, and Byram Healthcare (of which DSC is a subsidiary). I plan to appeal their decision and I was wondering if anyone else out there may have had a similar experience and had any success in fighting with their insurance company. If so, can you offer any suggestions that tipped the scales in your favor?

I had sort of the same experience…after almost a year of fighting…they said “sorry, but we made a mistake”…
I paid out of pocket until I found MEDICARE Blue…

Good luck with that. I spent months fighting them over an Omnipod, which I calculated the cost of and it's almost identical to the cost of other pumps retail. I had no real success in fighting them, but I learned something unique about United. If you file a BBB complaint, they sit up and take notice.

I also, through talks with the Virginia Insurance commission learned that they believe it should have been covered. So keep appealing.

I vaguely remember that I used to order supplies under byrem healthcare, no?

So far I was not able to get UHC to cover Omnipod. The argument is bad, as Omnipod is NOT more expensive. There is way less upfront cost, but the monthly cost is higher. Overall the cost is the same. I think that you should point in your appeal need to avoid disconnection while swimming (if you are a swimmer) and the need to use alternate infusion sites as in : back etc.
Please write an appeal, so we still voice disagreement with their policy.
Good luck,

I have had no issue getting omnipod covered with UHC via Edgepark.

Try getting the Omnipods through Byram; they definitely supply them. I originally got mine through Insulet, then Insulet told me they couldn’t supply me any more because my insurer had dropped them; I had to get them from an “approved supplier” instead. That ended up being Byram; they sell at a 10% discount off the Insulet end price.

Unfortunately we have to check our insurance coverage at the start of every open enrollment period; each year’s policy is different, even though it may have the same name, same group ID and same subscriber ID. Companies like Insulet have to negotiate with every company every year too; not just one government once for approval and once each year for a contract price.

Have your Doctor write a letter of "medical necessity", help him with it too. Make it sound like nothing else will work. This is a normal process for many insurance, so they are used to seeing these letters. That's my suggestion, and good luck.

I am a doc, and I wrote letters like those. Nothing works so far with UHC.

Byram is supplying agency and it can't supply Omnipods if insurance does not cover.

My advice is this: don’t let up, and make yourself the squeakiest wheel they’ve ever had to deal with. I’m an MD and have years of experience with the Prior Approval/Authorization song and dance that I routinely encounter when prescribing meds for my patients. I’ve learned not to accept “no” for an answer, which usually results in moving up the “food chain” of the damned insurance company until I reach the CMO. I always make sure to have my ducks in a row before every effing phone call in order to knock down their flawed reasoning not to do exactly what the insurance company exists for IMHO, covering the costs of its insured’s health needs. The “powers that be” eventually wear down and become tired of arguing with me, and eventually give in. Then I do my “Happy Eff You” dance. Until the next time.

Good luck.