Looking for input on comparing the cost of Medicare Part D plans in Maryland that cover the Omnipod 5. Cigna’s rep. says they don’t know the cost of a box so it is impossible to compare plans for the best price. Your experience and feedback is greatly appreciated.
If the plan covers it you should be able to look it up on each plan’s Formulary for Part D Medicare pharmacy items. It should show the copay for a 30 or 90 day supply. If the Part D is buried in an Advantage plan you’ll need to dig into each plan. My BCBS (secondary to Medicare) in MD has a $125 copay for a 90 day supply of my Omnipod DASH pods. In my case that’s for 9 boxes since a pod only lasts 2 days for me. It would be the same copay for the customary change every 3 days 90 supply for 6 boxes. Getting to a per box price will be a tough way to compare. The insulin for the pods will also be on their Formulary lists and you should be able to find it on their web pages. It’s a tedious job to check and if there’s a short cut, I haven’t found it. Best wishes.
The more informed Cigna reps will tell you that the problem is the drug formulary does not list Omnipods because they aren’t in the MediCare formularly, or they weren’t in April when I went on to MediCare (I was checking for Dash pods.)
I just got my monthly EOB for July 2025 from Cigna. These costs are for a 3 month supply of Omnipod Dash pods and the required insulin. It doesn’t matter what the insulin is and so long as Omnipod is in the formulary of the Part D provider the base price should be the same (because it is fixed by MediCare):
That’s 6 boxes of Dash pods, 30 pods; monthly cost is $552.01, cost per box (5 pods) would be $276.005. I don’t believe those numbers since I only paid $314.65; that corresponds to an actual price of $1258.60 (since the copay is 25% in the initial period and I was past the deductible at the end of April).
Therefore my assumption is that the MediCare price is actually $419.53 for a month ($1258.60/3). This is consistent with April (my first month on MediCare) where I paid $783.58; that includes the $590 deductible (not including the insulin costs which are clamped at $35/month):
($1258.60-$590)/4 = $167.15
$167.15 + $590 = $757.15
I think whatever crazy way the $105/month fits into the calculation may explain the discrepancies. If there is a math nerd out there this is an exam question 
I don’t think the Omnipod 5 pods will be significantly different but I do know that the Cigna rep couldn’t tell me what the cost was, only that Dash pods were covered. I think I also checked for O5 pods but you need to check yourself for those.
The first year the cost might make a very significant difference as half the year is paid on an ACA compliant plan and the other half on MediCare; the out-of-pocket costs do not carry over. The first “year” on MediCare and the last “year” on ACA are pretty much separate so we pay for two years in just one year when we go on to MediCare.
After the first year, however, we pay $35 per month for insulin; $420, leaving $170 of the deductible then the Omnipod (after that $170) is covered at 25%. If you assume my calculated MediCare cost of $419.53/month that gives $5034.40 per year (just for Omnipods), $4864.40 after the deductible so $1216.10 out-of-pocket. This leaves just $193.90 (MediCare $775.60) for other prescription costs.
This assumes the (new) $2000 per year catastrophic limit is not cancelled in 2026 but even if it is I’m not hitting $2000 in a complete year yet. My budgeting was based on $2000 for Part D (plus the subscription, which is $0 in my case).
Part B pump users with a MediGap Plan G (which costs extra money per month) save $2000 unless they have other prescription costs over prescription pump users because the pump and the insulin go onto Part B.
Thank you so much for your reply. In my experience, the Formulary for Medicare Part D Plans in Maryland consistently shared that the plans cover all but 17% of the cost of Omnipod 5 pods. The problem - each plan could not tell me their cost for a single box, a 30 day supply, or a 90 day supply so that I could determine my out of pocket cost. I can not compare the actual cost of the different plans (Premium + the 17% for the Omnipod 5 Pods). The insurance representatives by phone claimed they did not know the cost or gave me a cost range.
I decided on AARP Medicare RX Preferred by United Health Care - Premium is $89.20/month with no deductible and the estimated Omnipod 5 pods for 3 boxes per month (5 pods in each) will be $47/month per a link provided by an agent of United Health Care. Mail order may be less expensive for a 90 day supply but I was unable to obtain the exact cost. I will investigate once my application is processed.
Yes, this is quite the tedious process and extremely hard to compare apples to apples in order to generate one’s individual out of pocket cost. Thanks for your well-wishes.
I switched to Medicare last year. I’m convinced that someone thinks that seniors don’t get enough social interaction so they designed Medicare to ensure that we get the opportunity to talk to lots of people. And since giving us answers would eliminate the need for that next call …
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I think you are talking about MediCare Advantage here. MediCare Part D plans cover precisely 75% of the MediCare approved cost and the rest of the cost has to be borne by the plan. So, for those of us on genuine Part D plans (not MediCare Advantage or “secondary insurance”) we pay 25% of the MediCare approved cost after the $590 deductible and up until (including the $590) we have paid $2000.
MediCare Advantage are not Part D plans; they replace Part D and you get what you pay for (or not.)
@spdif any comments on this nightmare?
Yep. No one who is paid to explain it understands it. I’m not good at talking to people so it puts me at a particular disadvantage, although the people I did talk to just seemed to want to tell me what the myriad of options are without explanation.
The written word, while it might be about to be cancelled, is better; Oregon’s state guide to MediCare which, I believe, reflects the probably cancelled national guide, was long but informative. Both me and my wife read it all the way through, it wasn’t quite enough (finding the actual cost of Omnipods was not possible because of what seems to be a deficiency in the CMS database) but it was pretty good. Just not enjoyable as a good Vampire read.
Thanks John. I am referring to a Medicare Part D plan and not Medicare Advantage. Maybe it differs by State. I’m specifically referring to the State of Maryland. I know in our neighboring State of Virginia, the plans differ from Maryland’s. It’s as clear as mud!
They’re all the same; they are Federal plans, not State plans. MediCare costs are set by the Federal Government; our lords and masters. They don’t change. There is absolutely no State involvement, not even the Land of Mary.
The Part D plans are provided by private health care providers. They choose drugs off a list and negotiate with private pharmacy benefit manufacturers to get a price where they can make a profit, a dime.
On the ACA they can make a mint, on MediCare they don’t get nothing that the Federal Government doesn’t pay and it pays exactly what it’s been paid to pay; nothing else!
So no; you’ve been sold a can of beans. You pay for the drugs the plan provides and you pay exactly the same as anyone else for those drugs as every other dude.
Start here:
Read it all. The only choice is to be ■■■■■■.
Read it all; like school when you were 15, now you are 65. Do not believe any single thing you do not read on either medicare.gov or cms.gov, e.g:
Do not ever believe that anyone else will tell you the truth. That’s a sad fantasy born out of despair and reality TV. Next year (2026) do not believe those web sites either; they will be cancelled.
@John_Bowler the fixed price reimbursements only apply to Part B DME. Other Part B reimbursements work differently and as you noted Part D is different animal. Pharmacy plan tiers with %'s scare me to death.
@MEF Glad you found a plan. I took a look at the formulary for the plan you picked in two different Maryland zip codes. I didn’t see Omnipod on either. Odds are I picked the wrong zip codes, Maryland is complicated with your crazy neighbors, but if you found Omnipod coverage on a doc other than the formulary let us know so we can be more helpful to others. As you experienced searching for Part D Omnipod coverage is tedious so I’m always looking for ways to make it less terrible.
Ah! I just remembered how I solved the coverage problem (though not the cost issue). Omnipod is not listed on the medicare.gov Part D “compare plans” page and, even though Cigna did cover it, calling up the Cigna reps in April resulted in a “don’t know” response; it seems those reps were using the MediCare.gov information.
I got the information about coverage from Insulet, this web page:
In fact in April that had a list of plans and, IRC, not all Cigna plans available in Oregon covered Omnipod (I might be wrong about that) however Insulet no longer lists specific plans, just Part D providers. This may be because the plans for 2026 have not been finalized yet; Cigna plan information won’t be available until September and won’t be online until October 1 (only two weeks before open enrollment.)
I checked Cigna again just now and found that I can get the information, but I’m now signed up with Cigna for a specific plan (I wasn’t when I was comparing plans!) Here’s the low-down for OR 97526 on the specific Cigna plan I have for Omnipod 5 pods:
Mail order (Express Scripts) $344.85/month (10 O5 pods/month, 90 day supply) for “Omnipod 5 Dexcom G7g6 Pods (GEn 5)”.
I couldn’t get the pharmacy price; something is messed up on the Cigna web site.
Chris, thank you for your feedback. As John described, I had no success speaking /emailing with representatives from the Medicare Part D Providers in my area to find out what my out-of-pocket cost would be for the Omnipod G7/G6 pods. They simply could not give an answer. Like John, I contacted Omnipod at 1-800-591-3455. I was transferred to a helpful representative who asked me to visit Omnipod.com (click the drop down for Is Omnipod Right for Me, Then Cost & Coverage, then Medicare Coverage) while on the phone with him. He said every plan listed is guaranteed to offer the Omnipod G7/G6 Pods. Interested in the Medicare Part D Drug Plans (not Medicare Advantage), I made a note of the ones listed which are available to me in my zip code in Maryland. I investigated Cigna and UHC/AARP and chose the AARP Medicare RX Preferred from United Health Care (PDP).
Visited https://www.aarpmedicareplans.com/health-plans/plan-summary/20832/031/2025#PDP and was able to find my prescriptions on the formulary, including the Omnipod G7/G6 pods. My husband offers the following info:
Log into medicare.gov
Select health and drug plans
Select Find health and drug plans
Put in Zip code - find plans now
Select Medicare Drug Plan Part D
Find Plans - AARP Medicare RX Preferred from UHC (PDP) came up for me
Select plan details
Select plan website
Enter zip code / View plans
Add drugs
Select view drug costs
View costs by month – This is what the Omnipod G7/G6 will cost me as a Tier 3 product (although I picked Omnipod G7/G6 Pods, the website records the name as Omnipod 5 G6 on my list of drugs
Drug Price $363.2
Plan Pays $316.20
You Pay $47
The Omnipod Representative I spoke with stated that Omnipods are listed as a Tier 3 or Tier 4 drug in all plans. Tier 3 drugs have less out-of-pocket costs than Tier 4 drugs. If the Omnipod is listed as a Tier 4 Drug on the insurance formulary of the plan you are decided on, you may request your doctor to complete a Tiering Exception For. “Tiering exception: Ask the plan to cover your drug on our list at a lower cost-sharing level if this drug is not on the Specialty Tier.” If approved this would lower the amount you pay out-of-pocket for your drug. I hope this information proves helpful.
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Yeah, I mistranscribed my last Omnipod order; it was $314.65 for three months. So that’s more than double what your UHC monthly cost is.
I almost went with the AARP plan in April but I couldn’t prove that it was cheaper+better and it is UHC so I went elsewhere. I’m still not able to get the Omnipod prices (I search for Omnipod) on the medicare.gov website but I was searching on the pages for comparing plans.
Ah. My pea brain starts to understand, or not; so Omnipods are always covered on Part D but maybe under Tier 4? So I’m on Tier 4 and the sales person I talked too couldn’t find the Omnipod because she was paid not to tell me that it was not covered. That makes 100% sense.
Thank you for the step by step. Note that the Omipod plan finder only includes plans that participate in whatever system Insulet is using. I’ve done searches before and found Part D plans with Omnipod in the formulary that don’t appear in Insulet’s plan finder.
Chris, thank you for the information. Since I had no success confirming Omnipod is covered in the formulary of many Part D plans offered in Maryland, and I was unable to obtain clear information from insurance reps, with only a week to find a plan before my current insurance ended, the strategy of going to Insulet served me well. In future open enrollments, I hope to have more time to explore. Thanks again.
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How did you do that? Like @MEF I couldn’t see a way of finding out whether the Part D plans available to me at initial enrollment had pods in the formulary and I still don’t know a better way as we approach re-enrollment. Most of what I found was by direct experiment on the basis of insulin; that appeared reliably in the formulary and I eventually found out that Part D did not include Fiasp in the formulary (which is what I was using before enrollment). IRC I used medicare.gov to establish that.
So then I was back to square one and when I went through the list (of Part D providers in Oregon) - 5 different companies - I used the Insulet O5 list (IRC) and came up with just two candiates, UHC and Cigna.
Cigna won out because it was the only one with a premium of $0; the UHC plan (the “AARP” one) has an annual premium of $1005.60 so, given that the OOPMax is $2,000 and the deductible is always $590 that didn’t make any sense without being able to determine that I could really get Dash pods and that they would pay me for using them. (Do the math; the insulin, at $35/month, completely consumes any financial advantage!)
I’ve always ended up in a place where it seems to me that the enormous complexity of the US premiums, deductibles, copays, tiers, out of pocket maxima, is just there to make it impossible for us to make rational decisions.
I finally dug out my self-printed copy of the 108 page Oregon SHIBA document (think how much it cost me to print that, even though I did it double-sided). I think I got the numbers wrong in at least a couple of my posts and I maybe got my reasoning wrong; Part D plans have to cover “[drugs] that are not part of the plan’s formulary.” (That’s a quote from page 31 of the Oregon SHIBA “Oregon Guide to Medicare Insurance Plans”.)
From our point of view it does not matter whether the “drugs” are in the formulary or out of the formulary; we pay exactly the same % of the nominal (fictitious) price of those drugs. So if we meet the “catastrophic coverage” limit with drugs in the formulary we can just use anything we want; it will cost us exactly $2,000 per year (slightly more in 2026) regardless of whether we use drugs that are in or out of the formulary (so long as they require a prescription; OTC Insulin does not count!)
The formulary joke is just a trap to attempt us to change our medications to save the Part D sponsor money. It’s a fine trap if it pays; if it costs us less, but it doesn’t for T1s who use the Omnipod unless we can determine up front exactly what we will pay. So how do we do that?
Here’s the Mission Impossible challenge. I live in zip code 97531 and there are, this year (not next I’m sure) precisely 5 Part D sponsors:
- Aetna Medicare S5601
- Cigna-HealthSpring Rx S5617
- Humana S5884
- United Healtcare S5921
- WellCare S4802
How do any of us determine the exact cost of a 12-month supply of Omnipod Dash (or, easy version, O5) pods? The question is about this year, 2025; the answer, “Well, just ring 'em up.” Does Not Work; it’s hours on the 'phone to find they don’t know.
The only solution to this problem that is vaguely reasonable is one that points to an online resource (any online resource) which will fill in that single, essential number; the actual base cost (before the reduction to our co-pay) of 120 Dash or O5 pods; 24 5-pod boxes.
(c) John Bowler
@MEF was asking about this too. The short answer is you can’t. Some plans offer fixed copays to eliminate the risk or coinsurance but fewer plans are offering that option. There is no requirement for PBMs to publish the prices they tell the pharmacy to charge you although many companies are offering this feature as part of their plan search.
For the rest I’m going to make John’s post a new topic because I don’t want MEF getting a ton of emails while we work through his questions.
There is a requirement; follow @MEF 's instructions but before going to plan selection choose the option to enter drugs to find the cost. Given that we know how much we need in 12 months medicare.gov will give the total cost to us over 12 months. This is how much we end up having to pay.
This list should be sorted by “lowest drug + premium cost” and that will list the costs for the remainder of the year. During open enrollment (starting Oct 15) it will list the total cost; this is what we pay for the whole year.
It is possible to back-calculate the base price of each drug by repeating this one drug at a time, excluding insulin which is always $35/month; that works so long as the total cost paid by us in a year for that single drug is less than $2,000 (which it normally is even for Omnipods).
The problem is Omnipod specific; Omnipod is not in the list of drugs on “medicare.gov” so can’t be added to the list!
The only way we can get the price is to find someone who already has the plan and get them to post all their Part D prescription drug payments to date, along with the date paid (hum, maybe this isn’t necessary…) and solve the bit of math that results. Unfortunately that result is both zip-code and pharmacy specific as well as being plan specific.
@MEF found the cost for the AARP UHC plan apparently (fixed at $47/month, $0 deductible?) but the other plans in my zip-code have variable costs (see @spdif 's research elsewhere). My actual payments to Walmart show a base cost of about $420/month, $105/month after the deductible on the Cigna plan that I have in my zip code but that’s for Dash pods.