I just became eligible for Medicare on August 1 plus I have a supplement that I get through my former employer.
This has been one of the hardest months of my life. I have been working on this every day for a month.
So far I have no Omnipods because my usage exceeds the amount allowed by Medicare. I need a two day change not three.
I have no more Humalog because my Part D doesn’t cover it. They want me to use Fiasp or Admelog.
I have no Dexcom because the doctor failed to respond to their request for additional information.
Added to this all my prescriptions have to come from different places that I have no relationship with. Everything has changed.
All I have for supplies is what’s here in my house, some of which may only last a couple of weeks. I have no idea where any of my life giving supplies are going to come from.
I enjoyed using the Omnipod and hate to have to return to shots. I have done shots for 40 years and finally decided that I deserved something new and better. The Omnipod worked well for me.
I have a couple of planned trips coming up in the next six weeks. Now is not the time to have to switch to a whole bunch of new medications and procedures. I need the things I know I can rely on while traveling.
I had top of the line insurance prior to August 1st where I got everything I needed for very little out of pocket. I had no idea that Medicare was going to turn everything upside down.
I appreciate anyone who takes the time to read my rant. Thanks!
Honestly, I don’t know what to do or where to turn for someone knowledgeable to help me.
I’m using Adapt/Solera which I used to use through Diabetes Management and Supply. The pharmacy side gets me two day change with no problem and the regular supply department gets me my sensors and transmitter with no problem. The phone app makes it really easy to order and they ask in advance when I’m seeing my CDE and when I plan to see her again. They’re also shipping me 90 day supplies of everything.
Maybe review how things are written up? I had terrible times with Walgreens Community pharmacy and while Diabetes Management and Supply was not good in the past, I have had zero issues now.
I’m using Aetna Silverscript Plus as my drug plan. No issues with Novolog.
It’s a lot of work to fix it all but hopefully eventually it works out.
Hi. My name is Chris. I’m not on Medicare yet but this forum has taught me a lot about what to expect. There are lots of knowledgeable people here. Ask anything. Or just vent. We’re here for you.
I know you are busy but “inconvenient” is one of the diabetes complications everyone suffers from. Because you just started on Medicare you are in a very special place were you can change Part D plans before the end of the year. Changes go into effect on the 1st of the month. So if you can change plans to one with both Humalog and Omnipods on the formulary now is the time. When Can I Change Medicare Plans medicare.gov I’m happy to help you look through formularies. If you can’t change plans talk to your doctor, Admelog works just like Humalog for most people.
Hi Chris, thank you. I guess I’d be ok with going over to Admelog. I have been researching it. I can get the Omnipod but not in the quantity I need. I don’t get the full three days out of it. My insulin requirement is such that I only get two days plus two hours out of it. I would need 15 omnipods to get through a month rather than ten. They are rejecting my claim based on the volume.
Then it sounds like the mysterious “donut hole” is going to kick in and cause me to pay for it out of pocket anyway. Still not sure I fully understand that.
The stress this is causing me to have to switch everything out and start over with new and unknown products is tremendous!
I’ve been getting 15 Omnipod pods per month on Medicare Part D plan with no problem. My Part D is Cigna and my endo wrote the prescriptions that way. My insulin prescription is “up to 75 units/day” which seemed to help the pod’s prescription correspond to “every 2 days” even though its not exactly a match.
My recommendation is go to a mail order Omnipod supplier pharmacy who knows how to submit the claims and will coordinate with your doctor for the prescription quantity. I use Gentry Health (844-443-6879) for Omnipod mail order and they have been great.
The donut hole is an expensive problem with Omnipods as far as I can tell. The copays get high when you hit the donut hole but that seems unavoidable. The politicians are bragging about a $2,000 out of pocket limit for Part D but that has not started yet.
Have you gone through the donut hole yet or are you still new to Medicare? I keep reading that it’s supposed to go away in 2025 and be replaced by a less expensive arrangement.
My part D is requiring me to go through CVS Caremark for the 90 day mail order which seems unavoidable. I’m trying to get a prior authorization for 15 Omnis a month. The uncertainty of it all is nerve wracking.
Yes 3 years in a row so far. Usually I hit the donut hole around mid summer and stay there until year end. It results in higher copays for the pods but not a total 100% copay. There is a complicated formula for it all that will hurt your brain trying to figure out. Last year once I was in donut hole the copay for 15 pods was about $240.
Even though your Part D says CVS Caremark I would still give Gentry a call. They have Medicare specialists who might be able to get you on board with them, does not hurt to ask. The big chain pharmacies don’t have much knowledge about Omnipod and Gentry seems to be a regular supplier of Omnipods.
@Cinderfella
I have Medicare and a Supplement plan and a part D plan from a past employer. I get Omnipods for every 2 days and humalog. It’s the plan D you pick that decides formulary/coverage for Omnipods and Humalog. The Omnipods every 2 days is I’m pretty sure decided by how your doctor writes the script request. I had no hassles getting either one.
By the way, I believe the donut hole already changed this year??? Something about you only pay a percentage now when you reach the donut hole? Not sure, it’s something my plan doesn’t make me go through. I pay flat rates for 3 months supply.
Have you double checked what your Part D Formulary says about Omnipods? It should say something like
Drug Name
Drug Tier
Requirements/Limits
OMNIPOD 5 G6 PODS (GEN 5)
2
QL(30 EA per 30 days)
QL is the Quantity Limit. Other common codes are:
Prior Authorization (PA ) You or your physician may need to get prior authorization for certain drugs.
Step Therapy (ST ) In some cases, it is required that you first try certain drugs to treat your medical condition before we will cover another drug for that condition.
If the formulary agrees with the info you got I can think of a couple of less bad options than bouncing between pods and MDI every 90 days.
Find a different Part D plan.
Pay out of pocket for the extra pods. QL limits the covered quantity, not the quantity you can purchase.
Talk to your doc about using a little Lantus or Tresiba with omnipods so the reservoir can last you 3 days.
The worst part about the donut hole is the name. Must have been named by a T1D. No one else would malign such a delicious piece of cake. The coverage gap isn’t complicated but it does involve maths so 100% of people don’t like it. Costs in the coverage gap | Medicare
I have found Medicare to be extremely beneficial for me. We have regular Medicare, a Supplemental and Part D through my husbands past employer. None are an Advantage plan. Regular Medicare goes a lot by what your doctor decides is needed. The supplemental picks up my costs under Part B as long as it is a coverage done by Medicare in the first place. It can be a little convoluted. Like Chiropractor visits are unlimited, I had a limit before Medicare, but Medicare won’t do maintenance care only “treatment” care. Advantage plans work differently.
What’s covered under Part D is what is on their formulary decided by the specific plan you pick or in our case what his past employer decided they want to include. That can change. They have to use certain guidelines under Medicare rules, but Part D plans can vary. They have to supply insulin, but not necessarily all the insulins out there. Some have a tier system for different costs of which drugs you get. It just depends on the plan you get.
Medicare is awesome. It’s far better than anything I had before that. On Medicare, I can find the best doctors in the best hospitals whenever I need anything. I have traditional part A & B with a supplement on part B that covers everything worldwide 100% except for drugs. I have part D for that.
Medicare.gov has an awesome website where you can list your medications. It then gives you a list of companies and their annual cost for a plan that meets your prescription requirements and lifestyle. The only other thing you really need to look at is the insurer’s reputation. Anyone with regular medical needs does not want to deal with a marginal insurer.
Medicare Advantage plans are also listed on Medicare.gov, and they give the insurer an advantage. I have never known anyone who pays for their insurance to be happy with the cost and benefits of an advantage plan.
Initial plan setup is a learning process and a pain but with taking the time to do it right, even if you need help from a local senior center or other service.
@Cinderfella – Every state has a free service called the State Health Insurance Benefits Advisors or SHIBA. They are designed to answer questions and help people with the sort of questions you have. I have used their help many times to select the Medicare Part D drug plan each year. They are a helpful unbiased source of good information.
The rules Part D plans for 2025 are changing with regard to the “donut hole.” What these changes will mean exactly are not clear yet but will become known in the next few months.
I’d like to add that Omnipod coverage is not listed for Part D plans on Medicare.gov. The best resource for finding Part D plans covering Omnipod is the Insulet website or checking the formularies of plans.
Hi, this sounds stressful! I have Medicare plus insurance from my employment; I’m retired now. I have used Fiasp for a long time and it is my preferred insulin for my Omnipod that I change every 3 days. Good Luck!
I would suggest you look into the new Tandem Mobi pump. It is considered by Medicare (like all pumps except, as I understand it, the Omnipod) to be a DME (Durable Medical Equipment) and that means that the pump and all supplies including insulin, are provided under Medicare Part B. The pump is renewable every 5 years.
I have recently started the Mobi and I love it when combined with the Dexcom G7. It’s about the size of a Omnipod plus infusion set.
Once everything is set up with your endocrinologist (who you are required to visit every 3 months) the system just works fine.
I can understand your frustration as Medicare is not the easiest to work with but, once going, I have never had to talk to them.
Do not give up on the OmniPod! John58 is correct. All you need is for your doctor to write the prescription so that it covers 15 Pods a month with the “correct” amount of required insulin per day. I get all the OmniPods I need through Medicare at Walgreens. My prescription calls for “50 units per day” which allows me to get five vials of Humalog insulin for a 90 day supply, and extra Pods each month. So if John58 says that 75 units per day gets him 15 Pods a month, then use that figure when you request a new prescription from your doctor. Insulet Corporation also has a Medicare Help Line that you might want to call to get some good advice.
Sorry I’m coming to this so late, but if you would allow me to rant right along with you … please!
I have a chart, if accurate is “nuts”, just plain nuts to me. Sure, you can justify just about anything (the moon is made of cheese, etc.) but I’m sorry, as I said, if this is accurate it’s nuts!
It depends on how you insulin gets delivered as to what “Part” medicare it is covered under. (it’s nuts!)
Also, as nutty is the vagueness of the rules on the Medicare website. Sure they can’t cover every instance, but wholly cow…
