Medicare coverage gap vs Omnipod

I’m about to start Omnipod, like next week. (In prep and hope for getting the Omnipod 5 as soon as it’s available.) Because of my coverage, I’ll be getting it via the pharmacy channel rather than the DME channel. (I’m not sure whether this is a Medicare requirement or related to my specific Advantage plan. I know that I cannot get a free trial due to Medicare regs.)

I know my copay and what my insurance is paying – and that I’ll quickly hit the Medicare coverage gap, aka donut hole. Generally, drug makers are required to give a 70% discount when patients purchase drugs in the coverage gap.

So does Insulet/Omnipod provide the 70% discount?

It may not matter immediately, because I’m starting it either way. By the time Medicare Advantage renewals come up later this year, I should know from the EOBs (not to mention my bank account). Whether they give the discount may determine whether I change Advantage plans.

Of course I should be able to get this info from Insulet, but reps have been confused enough about my coverage that I don’t want to ask too many questions all at once :confounded: and figured someone here might have actual experience.


I am on Medicare Advantage, but I don’t have a pump. Someone I know on Medicare was pumping. She had her doctor prescribe the pump and insulin as durable medical equipment through Medicare part B. This was several years ago, but according to her this way eliminates the doughnut hole. Maybe so, maybe not.

Medicare Part B covers a portion of an insulin pump and the insulin costs, as long as your doctor prescribes it and it meets Medicare’s requirements.

Unfortunately Medicare does not consider the Omnipod to be a pump, so this won’t happen under Medicare,

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Eliminates the gap, but there’s a copay of 20% in part B, compared with a $35/month copay under part D. As Laddie says, this does not apply to the Omnipod under Medicare; it’s part D only, and you also get the insulin under part D. In addition, if I wanted to switch to a different pump, I would not have to wait since the Pod isn’t treated as DME. (Not that I expect to switch.)

Also no startup cost – they are sending me the controller for free.

Since I posted, I’ve found a few comments that seem to indicate that the 70% discount does apply. In particular, I found an Insulet annual report that listed the discount being increased to 70% as likely affecting their revenue. This will be a Big Deal – about $215/month OOP instead of $660 while I’m in the gap. Result is I won’t reach the OOP limit.


I have an Omnipod and a Dexcom. I am on Medicare and a supplemental insurance plan. Omnipod only goes through part D I gather because it’s disposable, which doesn’t make sense to me since my Dexcom is disposable too and it falls under part B. But that is what I was told. I think also Omnipod is sort of a recently covered option for Medicare, A few years maybe??

But for me, my insulin is $40 for a 3 month supply and my pods are $40 for a 3 month supply no matter how many/much I need through my mail order pharmacy supply.

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Yeah, I got that from the article I posted. As the Omnipod is sort of self contained and I guess is tossed out after use it’s not considered Durable, at least that’s my understanding from reading not actual use.

Does Medicare cover the controller device as DME?

I don’t think so. I tried out Omnipod a few years ago in order to try Looping and my Omnipod start-up kit (containing the controller) was covered by my Part D pharmacy plan. I had a horrible experience with Omnipod with lots of pain, bruising, insulin leakage, and erratic insulin absorption. My old lady skin and tissue couldn’t deal with the trauma.

IMO there is not much difference in how Dexcom and Omnipod work so it is weird that one is considered DME and the other one not. Supposedly Insulet has a history of not successfully dealing with Medicare and I think that they were just happy to get pharmacy coverage.

Insulet is sending me the controller. Just sending it, no charge. I placed the initial order of pods on a three-way call with the Insulet rep and the Walgreens CSR, so the Insulet rep knew I had placed the order.

Clearly this way they completely avoid the question of whether the controller is DME or pharmacy. It’s a free-floating freebie. It just falls out of the sky.

Why DME vs pharmacy? I’m not planning to stress my brain over that. I’ll just deal with how it is, and save the stress for something else. Plenty of choices!