Hi All:
I recently went on Medicare and as you all probably know they do not cover the pump, which I wouldn't give up for anything, although I've had the same problems that I often read about My question is about insulin. Medicare's website says that they cover insulin used in a pump under Part B, but when I brought the prescription to my pharmacist, he said he had never heard about it. Anyone have any ideas? Thanks.
insulin is cover by plan d which is the prescription part of medicare roy
I'm on a Medicare Advantage Plan and have the Omni Pod. My insulin is covered. ( I do have a co-pay). I use Novolog, and it's a regular Rx. I believe the prescription is made out for me to use 100 units every 3 days. I go to CVS.
I also think my meds are covered under Part D which is included in my plan.
I have a medicare replacement policy which means they do basically the same thing as medicare and dont cover the things medicare wont. Right now I get my insulin and test strips from Fifty50 Pharmacy. I like that they donate half their profits to diabetic research. I think they donate to JDRF. Anyway I have a co-pay on my insulin.I had heard that medicare pays for your insulin 100% if it is used in a pump but you have to have the right person file it. I’ve yet to find that person. 
I think the bigger issue here is that Medicare refuses to cover OmniPod although I understand that they will cover the Minimed tubed pump. An insulin pump is an insulin pump, and cost wise, they come out to be about the same at the end of four years. Minimed costs more upfront and less for infusion sets, while OmniPod is thousands less up front but higher Pod costs. My husband and I did the math, and in the end, they are about even. So the question remains, why is a tubed pump covered while a tubeless pump is not?
If over 10,000 people are now using the OmniPod pump, I would think that our Congressmen (and women) should start to pay attention to our united voices and pressure Medicare to cover the OmniPod as a recognized "medical device." I repeat, a pump is a pump... tubed or not. (I also wonder what will happen when Minimed comes out with their tubeless pump...)
I agree! The only explanation I’ve gotten is that Omnipod is considered “disposable” and the cost is more. I don’t know if they are considering the cost of thrown out insulin? I don’t throw any out, I pull it out and put it back in the vial. I think it’s more about how much can they make not on how much does it actually cost. In other words they cut a better deal with the other pumps?! Also, I use the freestyle strips in the Omnipod and all my suppliers are discontinuing them because… Freestyle is raising their price and insurances are lowing their reimbursement. It’s all about big business and the bottom line.
So here’s what I’ve come up with
I’m not good at math so tell me if I’m doing something wrong here. Minimed Pump 6500 one time cost for pump
Suplies monthly 1920 mo supplies X 12 mo = 23,040yr for supplies
23,040yr + 6500one time cost = 29,540 first year
23,040yr X 4 years = 92,160 over 4 years supplies only
92,160 + 6500 = 98,660 Total for 4 years of Minimed pump
Omnipod is 450 month
X 12 mo = 5400 year
5400 yr X 4 years = 21,000
How the heck is money an issue here??? Even considering there may be some inslulin thrown out. I was told it wasn’t covered because it’s considered “disposable” And this is a problem WHY!!! Insulin is disposable too and so is the tubing and crap you get with the minimed! In fact there’s more “disposable” with that than the Omnipod! sorry, i’m ranting.
They have probably never sat down and put pen to paper. So they dont realize the true costs. Also they probably dont even think about the cost of the supplies.
Yes, but it’s much cheaper if you can get it through Part B
So what can we do to put pressure on our Congress people? If we could get some doctors behind us also, that would be great. Any ideas?
barb what all do you include in your supply cost? I know there is the infusion set but it seems like you must be including something else to get to 1920. My supplies were always covered 100% so I’m not really sure exactly what the costs were. So I’m not doubting you I’m just curious.
I may have to go back and figure out what all my supplies were and the costs. I may find mine were even more. Who knows it may all depend on where you get your supplies as well.
The tubed pump billing codes are all the same, the omnipod pdm code is different, and isn’t covered.
WE know that; the point is to get it changed.
I have written months ago on this site on the subject.
I have researched Medicare regulations, found the original decision in 1999 on what was called CSII- continuous subcutaneous insulin infusion- and read the current basis for my denial by medicare.
I filed an appeal and am now preparing a fruitless effort in filing a Redetermination beofre an alleged “objective " medicare contractor. Gee- who butters his bread?
There is wording that states that any other device not coded a certain way-it is not Omnipods’ code- is denied as"not medically necessary”. There is no rationale stated for this baseless decision. it was also denied because the pump is not considered DME. However, as we all know, there is no difference with the other pumps. The regs seem to say that the device has to be rented- not purchased. How does this differ from covered pumps?
I cannot believe that Insulet does not appear to be making any headway. I am told they are trying but until a code is modified, I guess I will see medicare in Federal Court.
If anyone has any ideas, etc, let me know…
I am filing my appeal in 1 day. I waited 6 months in hopes someting change but it has not.
Leave you with the words of the last medicare discussion I had today when I asked for the rationale for approving 1 pump and not Omnipod- w" we do not need a rationale- we are the law".
I also find it strange and hard to believe that Insulet has made no progress. What about contacting a really good attorney and filing a class action suit. I’m ready. Has anyone tried contacting their congressionman? What about the ADA? Aren’t they a lobbying group?
If you already have the PDM you should just be able to order the pods. The pods are just a supply and Medicare covers supplies. They cover supplies for every other pump.
Should is the operative word here. Insulet files and medicare rejects!!!
I appreciate the comments.
First: I am an attorney and class actions are always possible, but there are various issues regarding the class and if all persons would qualify.
As for the issue of calling the pods a supply, it is interesting argument but Medicare Regs say that if the pump is not covered the supplies will not be!. Any other pump is deemed not to be medically necessary. It is ridiculous.
The Omnipod appears to be called an External ambulatory insulin delievery system and has a certain code. The covered pumps are apparently called continuous subcutaneous insulin infusion pumps (CSII). I do not know why or how the Pod gets a different non covered code but that appears to be the problem and Medicare just claims it will not cover this manufactuerer /supplier. I will continue the fight, however, because I am so outraged, especially when they say this pod and supplies are not medically necessary. But medicare advised they will certainly cover my hospitalizations, etc. that will be a consequence of going off the pump! How nice.
This is an example of things that drive me nuts… My insurance company (BCBS of Illinois) covered my pump and supplies BUT they would not cover the initial training regarding just how to use the pump. That’s crazy!!!
Is it your doctors office wanting to charge you? Because the pump company should give you training for free.