Medicare/OptumRx, OmniPod & U200?

Does anyone have experience with this collection of items? Just wondering how hard it might be to get the prescription approved - getting pens for pump fills - particularly when the pump says it’s only approved for U100.

With mildly low carb eating & no extenuating circumstances, my 200 units of U100 lasts 2 1/2 days. But if I skyrocket like I have the last few days being sick (not Covid), where it’s been a struggle to get down near 150, I’m using more than 100 units/day and not getting 2 full days out of a Pod.

Omnipod is covered under Medicare prescription Part D and so is your insulin. You need to pick a plan that has your desired pods and insulin in their formulary. That may or may not be easy to do and you need to have an endo that will go to bat for you. Omnipod is hugely expensive under Medicare compared to a tubed pump. Good luck.

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I’ve got great coverage on parts A/B and D and pay the premium to do so; worthwhile as most of my health issues are chronic and fairly predictable.

I’ve been using OmniPod since January. I’ll be in the donut hole when I order refills at the end of the month so I know that will be an expensive order. (My last 90 days was only $135 for 45 pods mail order thru the Walgreens Community Pharmacy that Insulet referred me to.) That’s the main reason I want to go to U200 - I want to get the full 72-80 hours, and reduce my requirements to 10
per month from 15.

I’m not worried about convincing my Endo, she’s been thrilled with my progress and self-management. That’s why I’m wondering if anyone has been successful at getting approval from OptumRx.

That makes a lot of sense. Good luck getting it worked out.

Which is the preferred insulin on your formulary? If it is Novolog then it may be a bit harder. OptumRX is one pharmacy benefit manager that likes to “exclude” things (not on their formulary). That REALLY makes things hard.

They moved me TO Humalog a couple of years ago, so I’ve got that part

I am on Medicare and my Endo approved a non U100 insulin for my Omnipod. Covered under Part B since Omnipod is a pump even though Medicare puts the pods under Part D. Good Luck and be persistent if you have to… :sunglasses:

I just got notice from UHC that Basaglar, Tresiba, and Levemir are to be excluded (It was supposed to happen a month or two ago but because of Covid they keep pushing off the change). Since OptumRx is technically “owned” by UHC (or UHC is technically “owned” by Optum- not sure which way it goes) I’m guessing that what you are looking at is “exclusion”. It may still be able to work since you would be on a Medicare plan. Medicare may have stipulations that prevent the prescription coverage from totally excluding something from a plan. Out of curiosity, wouldn’t you get drug coverage through Tricare for Life? If that is the case then I think your pharmacy benefit manager would be Express Scripts (I think they are the PBM for Tricare for all 50 states). I know of some people with that insurance and they get their prescriptions through the Tricare benefit (or at the base).

Are you confident that you could get your endo to prescribe U200 for your pump. To use U200 in a pump would require reprogramming the pump. You may have faith that you can do it but the lawyers that rule this world have this great fear that there is the slightest chance that you may make a mistake and cause the pump to over bolus or over basal by 200%. If something like this actually did happen and someone was harmed your endo would not have a leg to stand on and his insurance company would be at the mercy of the plaintiff’s lawyers.

You are only the 2nd person I know to accomplish this. My pharmacist even tried to get my insulin covered under Part B when I asked her not to (I didn’t want to waste the time). Medicare considers OmniPod an injection device, not a pump.

I’m not former military. I’m not even a Senior quite yet. I’m on Medicare due to disability.

You don’t have to reprogram the pump, just set the I/C ratio and CF to account for twice the insulin per unit, so, for example, my 1u for 5g would become 1 for 10. I believe it’s not always a straight calculation, but others have done this and worked it out.

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It did take some work and persistence to get covered. I spent some time here on the forum to pick other’s brains to figure out the obstacles.

I went into Medicare with Omnipod already in use. My Rx simply says “inject up to x units per day via pump”. Medicare assured me that they “do not dictate brands of insulin or pumps”. Your doc has do to the correct certification quarterly to Medicare to get the insulin covered for pump use. IDK those particular forms. I have BCBS as secondary insurance. They covered Omnipod as a DME pre-Medicare and still pick up the portion Medicare doesn’t cover even though the pods shifted to Rx, Part D now.

No special programming for the Omnipod. As you have said, simply set the right ratios. A skilled CDE or Doc should be able to do that. The CDE who set up my Omnipod had about 30% of her clients on off label or not-U100 insulin, so she got it almost 100% right at the get go. My A1C dramatically improved in 3 months. Love it. Good luck! :sunglasses:

Also Insulet tells me they are still working the Medicare coverage issue. (The illogic behind the denial hurts my brain. If not an infusion device, what is that plastic bit sticking my skin delivering medication with tubing only 2mm long???) Insulet asks that I sign a Medicare form annually allowing them to bill Medicare even though we all know it will be denied. They are my supplier not a pharmacy for my pods. Then they bill my secondary insurance BCBS who treats the pods as DME. FYI they bill $1350 but accept the BCBS plan allowance of $799.50 for 3 months of pods. I pay nothing because my BCBS plan pays the usual 15% copay for DME when Medicare became my primary. Indeed I am thankful to have great coverage. :sunglasses:

My son uses U200 insulin in his pump. We switched a few months ago and are happy with it. Although it took him several weeks of tweaking to adjust his basal and bolus ratios. For some reason it didn’t work to just cut the ratios in half. Also this insulin peaks slower and has shorter tail, so this was another thing to get used to.

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This is what I mean by reprogramming your pump, You must change the bolus and basal settings.