Medicare and Omnipod Dash

Has anyone been able to get the Omnipod Dash under medicare part D?
I haven’t been able to get it yet.
I heard it was approved about a year ago.

John

Was it approved under part D or DME?

Part D. From Insulet’s website:

YOU CAN FINALLY CHOOSE THE OMNIPOD®SYSTEM THROUGH MEDICARE PART D.

For more information on coverage, how to sign up, and a full list of Part D plans, please call our Medicare Access team at 1.877.939.4384.

Coverage through the Part D pharmacy benefit means:

  • Coverage for patients with both Type 1 and Type 2 diabetes
  • No burdensome paperwork
  • No-charge* Personal Diabetes Manager (PDM) comes with first box of Pods for low up-front costs
  • Patients are no longer locked into a 5-year upgrade cycle

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services

7500 Security Boulevard

Baltimore, Maryland 21244-1850

CENTER FOR MEDICARE

DATE: TO:

FROM: SUBJECT:

January 5, 2018

All Part D Plan Sponsors

Jennifer R. Shapiro, Acting Director Medicare Drug Benefit and C&D Data Group

Medical Supplies Associated with the Injection of Insulin

We are issuing this guidance regarding Part D coverage of products used for the delivery of insulin for the treatment of diabetes. With the introduction of new insulin delivery devices to the market, questions have arisen about Part D coverage for these products. Specifically, we have been asked whether newer insulin delivery devices that are not covered under Medicare Part B meet the Part D definition of “medical supplies associated with the injection of insulin.”

Section 1860D-2(e)(1) includes “medical supplies associated with the injection of insulin (as defined in regulations of the Secretary)” in the definition of a “covered part D drug.” Our regulations at 42 CFR 423.100 specify that this includes syringes, needles, alcohol swabs, gauze, and supplies that are directly associated with delivering insulin into the body. CMS also specified in the preamble to the January 28, 2005 final rule that “insulin delivery devices not otherwise covered by Part B, such as insulin pens, pen supplies, and needle-free syringes” were included in the definition.

The examples that were previously provided were never intended to be an exhaustive list of products that could be covered under Part D. Instead, they represented our understanding of the types of medical supplies associated with the injection of insulin that were available at the time. Since that time, newer insulin delivery devices in the form of both mechanical and electronic insulin pumps have become available that are not coverable under the Medicare Part B durable medical equipment (DME) benefit. Consistent with the Part D policy to allow coverage of insulin delivery devices that are 1) directly associated with delivering insulin into the body and 2) not otherwise considered DME under Part B, Part D sponsors may provide coverage of such products under Part D as “medical supplies associated with the injection of insulin.”

We expect that technology will continue to advance and that “medical supplies associated with the injection of insulin” will become significantly more sophisticated. Part D sponsors may include such supplies in their benefit consistent with the policy discussed above. However, while CMS recognizes such products as medical supplies that are alternatives to insulin syringes, CMS does not require Part D sponsors to include them on their formularies, and sponsors may apply utilization management criteria if they include such products on their formularies. As new products become available, Part D sponsors may evaluate these products for formulary placement and medical necessity and, subject to Part D coverage determination and appeals requirements, allow access and restrict use accordingly.

If you have any questions concerning this memorandum, please send an e-mail to PartDPolicy@cms.hhs.gov.

1 Like

What reason are they giving you for the denial? A little more context is needed in this story.

They didn’t give any reason whatsoever. Insulet is supposed to be handling it.

John

I tried out Omnipod last summer for the first time ever. I chose the older Eros pods because I wanted to Loop. But I could have gotten the Dash instead. Both were in the formulary of my Cigna Part D Pharmacy plan.

I do not think that Omnipod is in the formulary for all Part D plans so that may be your problem.

I am glad that I hated Omnipod because it was hugely expensive since it was in Tier 3. Plus my insulin would have also been covered under my drug plan rather than through DME with my tubed pump.

I got the Dash Welcome Kit on New Year’s Eve day.

First, my Endo’s office made the contact with their OmniPod rep and then over the next 3 days I had a series of OmniPod people helping through each stage - Medicare approval, actually making a 3-way call with me to a specialty Walgreen’s that does mail order, following up that it went smoothly from there, and then scheduling my training with the trainer for the region. Easiest medical supply I’ve ever gone through.

I have an AARP Part D plan.

I don’t understand why I haven’t been able to get it. I was going through Insulet like you did and have United Healthcare Part D. Insulet is a provider for them. One other problem is that no one from Insulet has returned any of my calls. Something weird is going on.

John

1 Like

What part of the country are you in?

which UHC part D do you have? Just because Medicare approved it, doesn’t mean the Insurer has to cover it.

Just Googled AARP UHC Part D. OmniPod is not listed on their 2020 formulary

I don’t think they list any “equipment” on their formulary only drugs, but I can promise you it’s covered. I just got a 90-day refill of 45 pods thru my AARP/UHC Part D.

Insulet must be processing the order incorrectly then.

@DrJohn - Try this guy. Adrian Jablonka. He is an Inside Sales Rep at Insulet who had responded to my original request for a demo kit and was getting me started until my local sales rep (in Southeast PA) got involved: ajablonka@insulet.com / (978)-932-0549

Thanks for that info. I will call him tomorrow (Monday).

John

Omnipod is shown in the formulary of my Part D Cigna Healthspring plan.