Medicare not covering the OmniPod Insulin Pump

#1

Hello, I am new to this forum thing. I have never done this before but I am completely worn out fighting Medicare on the OmniPod Insulin Pump coverage issue. But I have found a possible way and a possible move to get a foot in the door and for the program to look at the OmniPod differently. Follow my logic, hopefully it makes some sense, and see if the outcome is as clear to you as it is to me. There are several hurdles to overcome. I will try to outline and debunk the the issues that I am aware of one by one.

  1. PDM- technically the PDM is covered by Medicare in many cases because it has a built in blood glucose meter that is covered by Medicare. So when the doctor issues the prescription for the PDM, it is listed as a glucose meter and thus follows Medicare rules.

  2. POD- the pod is considered disposable and therefore not durable medical equipment. However, the delivery system from any pump system is “disposable.” The reservoir is a one time use product, therefore disposable. The infusion set is again, one time use and therefore disposable. If the logic is followed, the delivery system for the OmniPod system follows the same lines as the reservoir and the infusion set. Medicare seems to have no difficulty paying for the disposable parts of the current allowed pumps. The difficulty seems to be with the definition of “disposable” and this argument appears to cover it.

  3. Cost- Minimed Pump- Cost of $7,000 dollars. With a 5 year warranty this means the pump cost a total of $116.67 per month to own. Supplies are as follows. 3ML Reservoir package of 10 costs $39 dollars. 1 package of 10 lasts 1 month approximately. 23 Inch Infusion Set for the pump in a package of 10 costs $139 dollars. 1 package of 10 last approximately 1 month. Total cost per month for the Minimed Insulin pump system equals $294.67.OmniPod- The ONLY recurring monthly cost of the OmniPod system is the Pods themselves. The cost of a package of 10 Pods is $299 per month. No other supplies are necessary with the OmniPod System. A new PDM will be an additional cost in the future of approximately $499 dollars. A onetime fee. The new PDM is guaranteed for 4 years. Adding a cost of $10.40 per month to the $299 bringing the total cost of the OmniPod to $309.40 per month. Also take into consideration the savings produced by the insulin savings per month. As I at one point personally used the OmniPod, I have medically documented evidence that proves that my insulin usage dropped by 35% vs the MiniMed pump system. Giving a +/- of 10%, that savings of insulin costs for Medicare could be huge. Thus actually saving money allowing the diabetics the opportunity to use the OmniPod covered by Medicare. Medicare would save the following money if I were allowed to switch to the OmniPod.

MiniMed Insulin Pump system cost per month = $1890+$116.67+$39+$119=$2164.67
OmniPod Insulin Pump system cost per month = $1172+$10.40+$299=$1481.40
Total Savings equals $683.27

That is one Diabetic. Multiply that by the thousands of diabetics currently covered by Medicare and being denied the OmniPod. The taxpayer savings is enormous!!!

What we need is every diabetic that wants the OmniPod as a possible option for diabetes care to be covered by Medicare to contact their Senator and Representative and show them the change and why this antiquated law must be changed. I cannot do this myself! I need assistance. I have been fighting this for 18 months. I have made ground but need help.

Please let me know if this makes sense! Comment any questions and I will sincerely try to answer.

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Omnipod medicare coverage
#2

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#3

If you can believe what top management has said in earnings calls and other events with investment analysts, gaining Medicare approval is a top priority at Insulet. CEO Patrick Sullivan mentions it often. With Dexcom recently getting Medicare approval for its G5 continuous glucose monitoring system, many believe that approval for the Omnipod system is near. I think you can rest assured that company officials recognize the huge potential of the Medicare community and are working diligently to gain approval.

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#5

Well, Jimbo, I’m not here to prove or convince you of anything. I’m just sharing my understanding of what has been going on for a long time. The fact that approval has not yet occurred doesn’t mean negotiations haven’t been vigorously pursued. This is a government agency we are talking about, so you can draw your own conclusions about how quickly things move. It is a recurring topic of upper management, and they are not ignoring a large potential market. I’m sorry your lawyers haven’t received assistance. I do not know Pat Sullivan, but you might try emailing him. I think their corporate email address system is first initial, last name @ insulet.com.

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#7

The Omnipod has not been approved by CMS, the agency that administers Medicare and Medicaid, for Medicare patients. Insulet is working to have that determination reversed. Are they involved in individual cases like yours? Probably not. Until the system changes its rules, I would guess there’s little chance for getting approval on an individual basis. You’re bitter. I get that. I hope, as I’m sure you do, that approval will come soon for all Medicare patients, not just a few willing to go through an apparently futile appeals process. The company is putting significant effort toward that end, even if they are providing little support for individual appeals. I have no doubt about that. You may believe what you will.

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#9

My information comes from listening to and reading transcripts of quarterly conference calls with investment analysts and other events like the company’s Investor Day late last year. The topic of Medicare coverage is discussed at nearly every one of them. Sullivan says he is working diligently to get this approved. While you may doubt, I believe him. Why would he not be making every effort to secure approval for something that would create many new potential customers for Insulet? This is America, a capitalist system. Companies are owned by their shareholders, who appreciate management that increases earnings by finding new customers. As a customer and an investor, I (unlike Thomas) believe Sullivan when he says he’s making every effort to open up this potential new market.

At the Nov. 3 quarterly call, Sullivan said, “Not any new updates (on Medicare reimbursement) other than we continue to work very closely with CMS.”

In the prior quarter, company president Shacey Petrovic said, “Medicare (and) continuing to increase Medicaid access are two things that could really make a difference for our business.”

In the April conference call, Sullivan said, “I continue with CMS coverage for Medicare beneficiaries being one of my top – if not my top – priority.”

I firmly believe the company wants this as much as you and I do.

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#11

Here’s one thing in writing. It’s an email I received from him with a link to create a letter and send it to the Centers for Medicare and Medicaid Services.

The guy isn’t a member of Congress. What do you suppose he should do? Obviously getting Medicare coverage would make the company more money. Of course Sullivan wants that. He’s not going through each person’s case one-by-one.

Are you saying he doesn’t want Medicare coverage? That makes no sense.

And if you are instead saying he isn’t doing enough, it may be because you don’t have access to his calendar and aren’t aware of his schedule. Just because it hasn’t happened yet doesn’t mean he is not trying.

Email from Sullivan:


We have exciting news to share with you! Recently, several prestigious organizations have joined our effort to ensure that people with diabetes don’t lose their access to the Omnipod® Insulin Management System once they are no longer covered by private insurance. These include:

+ American Diabetes Association
+ The American Association of Clinical Endocrinologists
+ The American Association of Diabetes Educators
+ The Black Women’s Health Imperative
+ The Endocrine Society
+ JDRF
JOIN THE CAUSE!

The Omnipod® System has changed the lives of thousands of people living with diabetes. This unique tubeless insulin pump system was cleared by the FDA over 10 years ago and is still the only FDA-cleared insulin delivery device NOT reimbursed by Medicare.

As a result, many stand to lose access to the Omnipod® System when they transition from private health insurance and into Medicare. I’ve had constructive and promising conversations with Medicare officials recently about fixing this problem, which makes your voice and support at this time all the more important and helpful.
JUST TWO CLICKS CAN MAKE A DIFFERENCE!

Now, with your help, we can make even greater strides in ensuring Medicare-eligible Podders™ keep their preferred insulin delivery system. I am asking you to act now and help your fellow members of the Podder™ Community by engaging your Members of Congress who serve on the committees that are most influential with the Centers for Medicare and Medicaid Services (CMS), the federal agency responsible for Medicare.

+

Click here to send a letter. We’ve provided a suggested letter that you can edit with your personal story. All you need to do is enter your name, email and address, and our partner’s online service will automatically email your letter to the appropriate offices.

+

Click here if you have already sent a letter. This will confirm your activity and help us understand the true impact of this important effort!

Your personal involvement in this effort can make a real difference. Thank you in advance for your support!

Patrick J. Sullivan
Chief Executive Officer
Insulet Corporation

#12

Can you share a little bit of detail on how it reduced insulin usage? Was is less waste? Better absorption? Any further information you can give?

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#13

Jimbo, good luck to you and your wife.

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#15

Did you really think I was attacking you? I’m not sure what I said that was an attack.

#16

Wow.

#18

Jimbo is obviously very upset, to the point that I think he misunderstood the intentions of others here. It’s a shame because we are all in this together, and I don’t believe anyone was trying to criticize him, only to help him see that Insulet is not “sitting on its hands” in regards to Medicare approval. Apparently, he’s just not open to that side of the issue right now. I spoke to an Insulet rep at my recent endo visit, and she said they believe that approval is near. I hope she is right. In the meantime, I don’t think there is much that can be done for individuals seeking exceptions to current policy. Good luck to all.

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#19

Thanks for acknowledging @Jimbo31’s concerns and for bringing us back on topic. I am interested in the Omnipod pump but am approaching Medicare age (eeek!) and so am hesitating to go that route.

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