Medicare

I know this has been asked but does anyone know if there is an insurer under medicare (DME, prescription plan) that covers Omnipod insulin pump and/or Dexcom CGM? I go on medicare Oct. 1st and trying to find one is impossible.
I need some help!

Based on a search of other posts, it appears MC does not cover, but many have gotten coverage thru a supplemental plan.

Medicare, along with a secondary AARP pays under DME entirely for DEXCOM. Also for your insulin and test strips which you’re using with your Omnipod PDM. Unfortunately, Pods aren’t covered under Part B, but they are covered under your Pharmacy Plan Part D.

For me, Part D is no bargain. I need to examine what other Plans are available. Also, regarding Dexcom, your Endo has to fax them documentation stating how many times a day you do finger sticks.

I am looking to switch from dexcom to senseonics it is confirmed more accurate by fda. No more changing sensor every 7-10 days. 90 days sounds better plus the overall cost is lower.

If you are still covered under private insurance plan before retirement, you should contact Dexcom immediately to inquire your medical and prescription drug insurance companies for eligibility. My medical insurance company (UHC) does not cover CGM, citing it is not a necessity item for T2DM. My prescription drug plan (Express Scripts/Medco) covers Dexcom G6 entirely after meeting my annual out of pocket maximum. Contact Kristel, a new account rep of Dexcom, 858-240-8372. She is very nice and provides the answer in one day. I received Walgreen Community Pharmacy phone call and my Dexcom G6 was dispatched in two working days.

Currently the Dexcom G5 is covered by Medicare and there is some discussion that the G6 will be covered by the end of the year. I’ll believe that when I see it. The G5 is covered under DME Part B. If you have Basic Medicare along with a supplemental (medigap) plan, Medicare will pay 80% of the cost and your supplemental will pay the remaining 20%. If you have an Advantage plan, you may be responsible for the remaining 20% depending on how your plan covers DME. Currently some Advantage plans are already covering the G6 because they are allowed to cover things that Medicare doesn’t.

The Omnipod is technically covered under the Part D drug plans but at this time it is not on many formularies yet. Hopefully there will be improvement in that in 2019. However if you plan on using the Omnipod with Medicare, you should check the formularies of drug plans you are considering. Once again Advantage plans can be different and some plans have been covering Omnipods while Medicare didn’t.

If you have Basic Medicare and a supplement, in most cases the Omnipod ends up being much more expensive than a tubed pump. My pump and all of its supplies are covered under Part B DME and this also includes the insulin used in my pump. So with Medicare paying 80% and my supplement paying 20%, I have no out-of-pocket cost for any of this. It is hugely beneficial having my insulin in Part B because it is not included in drug donut hole calculations.

Because the Omnipod is not considered DME, the insulin for the Omnipod is reimbursed under Part D where you have a larger deductible, copays, and the dreaded donut hole.

If you are active on Facebook, you might want to consider joining the Seniors with Sensors group where there are lots of people to answer your Medicare questions. The group was originally founded to advocate for CGM coverage by medicare, but we discuss pumps, insulin, and all sorts of stuff affecting seniors with diabetes.

I am planning to enroll in Medicare Plans B, D and F next spring after retirement. There is a quite a bit of financial burden for insulin pen supplies (or Omnipod) under Plan D. UHC’s medical policy # 2018T0347Z, “Continuous Glucose Monitoring and Insulin Delivery for Managing Diabetes” has detailed explanation of their policy. Although I have no experience of the DME coverage for Insulin Infusion Pumps and CGMs in Medicare Plan B, I feel this UHC’s medical policy for DME is probably close to Medicare Plan B and D.

I just got a Dexcom G6, which was covered under my current prescription drug plan by Express Scripts/Medco, subject to my annual deductible. This drug plan also covers the Insulin Infusion Pump accessories, except for the pump itself, which is covered under UHC’s DME policy and subject to higher deductible. For T2DM, the C-Peptide test must be below 110% of low normal range to qualify for Medicare Plan B DME coverage. Then it will be paid for by Medicare Plan B.

I am also looking for “Diabetes Friendly” Insurance Companies for Medicare Plans B, D and F. Maybe all insurance companies are the same under Medicare guidelines. Appreciate to learn more from others who have experiences.

I’ve signed up to A,B,F and just signed up for Express Rxplus plan D. I was told by Omnipod that I have to wait until Oct. 1st to do anything about coverage with Express. They have to send special paper work and request they add this exception to their formulary. So not until Oct 1st, then send paperwork and wait 2-3 weeks and they can still deny. So I have to enroll THEN find out if they’ll cover, seems very wrong.
Dexcom is much easier, a new script and notes from doctor and should be covered. This is terrifying.

I have A,B,D,F.

D is Silverscript Choice. 2018 Formulary covers both Omnipod and Dexcom g5.

I still use a Medtronic pump, so I have no direct experience with Omnipod co-pays. However, I use Dexcom g5 and have never paid a co-pay.

Dexcom G5 is under Plan B DME and Plan F covers the Plan B deductible and 20% copay. Omnipod is under Plan D, there is a copay. Hope Dexcom G6 is covered under Medicare Plan B next year. @anon31175731, who is your Plan F provider?

BCBS of Alabama