Is anyone else in the same mess I am in? After using an Omnipod pump for over 5 years, I just went to refill my pod order and was told is was DENIED!
After many calls back and forth, I have now been told by 2 United Health Care Benefits people that they have determined a “more cost effective way to manage my diabetes” HOWEVER, they have no way of telling me what that is. REALLY???
I now have calls into my doctor, diabetes educator and at this point have not received a return call. Of course, with the holiday here, that doesn’t help anything and I have about 30 days of supplies left.
SUrely, somebody else out there has this same debacle going on and can offer some help.
I am using a non-medtronic pump with UHC. I have to use UHC’s preferred supplier (for my t:slim that’s Solera) and can’t buy my supplies from anywhere else. As I understand it, UHC doesn’t cover buying a non-medtronic pump without hoops, but will pay for supplies still.
Sherry, I would advise you to immediately contact your congressional representatives, i.e. Congressman, and both Senators of your state to ask them for assistance if you prefer continuing using the Omnipod vs. a Medtronic pump. No one should be forced to switch insulin pumps unless you are of Medicare age. Unfortunately, Medicare will not pay for Omnipods because they only have a “so called” useful life of three days. Many of us seniors have been fighting Medicare over this for a number of years now. From the sounds of it, it’s possible UHC has struck a deal with Medtronic, and wants the diabetic patients they cover to use a Medtronic pump because of dollar cost savings to UHC, but I’m not sure? I’m sorry, but get ready for Trump Care Folks!
The original release of the UHC/Medtronic policy (p. 7 of the following document says: “UnitedHealthcare will continue to cover insulin pump supplies for all brands of insulin pumps that our members currently use while their insulin pumps are in- warranty and are still functioning properly. They do not need to make any immediate change to their pump and will not transition to a MiniMed pump until their pump is both out of warranty and not functioning properly.”
Please note that this document is from May of 2016.
If I were you, I would go to an Omnipod users group on Facebook and see what others are experiencing and see if appeals are working to continue to use the Omnipod.
I thought Omnipod was not covered by this UHC mandate about switching to a Medtronic pump. Omnipod is covered differently by UHC than any other insulin pump. It might come under Pharmacy benefits instead of DME?
After multiple phone calls here is where I am on this.
Diabetes educator said that they shouldn’t be doing this as I’m still under warranty (as you stated) but that doesn’t resolve problem.
Omnipod rep got right on it and said that taking order thru Advanced Diabetes Supply under Pharmacy benefits rather than durable medical should make order go thru.
I had been attempting to get supplies thru Edgepark as they said cost would be $60 per box vs. $84 at ADS.
This sounds like a bandaid but by 5 pm CST today I should know if supplies are shipping thru ADS.
I feel that I’m walking a tightrope but from what y’all are saying, Medtronic sounds like my only option going forward. I have 1 year 3 months til reaching Medicare age.
Then is the Dexcom covered under Medicare-have heard that’s a problem too.
Thank you sooo much for sending that link!!
Odd that this denial came about when going thru Edgepark.
Did you notice that the language says that a change to Medtronic will be made when BOTH your pump is out of warranty AND not functioning properly!
I have been on Omnipod for 5 years, but when warranty expired, had switched to Animas as diabetes educator thought that the insulin delivery dif might improve A1c’s.
It didn’t, and I detested going back to tubing, so went back to Omnipod. Omnipod shipped me a new PDM when mine failed, but technically I’m probably in warranty on Animas and out of warranty on Omnipod.
Have you seen an update from the link you sent? They said this went into effect 4/17.
Also let me know how you found this link.
So sad that the people working for UHC in the denials part had no idea what to tell me on what pump they were recommending-all they could say was “talk to your doctor.”
The link I provided was from the original UHC announcement and was available around social media when it was released in May 2016. Because I neither use an Omnipod or have insurance through UHC, I mostly have been out of the loop on how the UHC/Medtronic mandate has been enforced. Like @Clare3 my memory was that Omnipod coverage was not affected and she is maybe right that it is covered through pharmacy benefits.
You probably know that currently Omnipod is not covered by basic Medicare although some Advantage plans cover it. Technically the Dexcom G5 is covered but suppliers and regulations have still not been finalized. I am optimistic that it will be worked out soon. I started Medicare in April and fortunately have enough Dex supplies to carry me through for a while.
Sean,
I reached out to Advanced Diabetes Supply and my problems were resolved almost immediately. 877-838-3026.
I have a long explanation as to why this all transpired, but ADS got it worked out. Are you United Health Care? That’s my carrier, and has been for over 15 years.
Yes United Healthcare is my provider. I spoke with one person and they said that the supplies are no longer under my pharmacy benefits and are listed as durable medical equipment. Which they want me to pay full price until I meet my deductible, which isn’t going to happen.
Hi, Sean, I am just wondering if you were ever able to resolve your issue. I am experiencing something similar where I can no longer get them covered as a pharmacy benefit but UHC has also denied my claim for the Omnipods as DME.
I don’t know if this would help, but I’ve been told that each vendor that we talk to when we order supplies, actually talks to different “groups” of UHC people.
50/50 pharmacy told me they could not get my supplies, but Advanced Diabetes Supply got them right away.
I don’t know if using different suppliers makes a difference, but that was my experience.
Thanks, Sherry! I’m currently going through the dreaded appeals process with UHC who have apparently determined that the Omnipod is not a medical necessity, because, of course, they are the experts on my body and what the best treatment is for me… I did try to go through ADS initially and it was rejected as a pharmacy benefit. Maybe I will try to get it ordered through them again while I await a decision on my appeal.
The key to winning is giving a reason why you are unable to use the Medtronic pump. It has to be something more than what you like, or what you prefer. Unfortunately, appeals are not won on the basis of someone’s preference.
Why are you not able to use a Medtronic? Find a reason and base your appeal on that.
Example, a lot of times employment requirements might prevent someone from using a tubed pump.
Sherry, Thanks for your information. Are you still currently getting your Omnipods through ADS? I was told they were not the preferred supplier for UHC and was referred to Edge Park by UHC. From there I was told the pods would be filed under DME and i would have to meet my Deductible before they would start paying.
I have just come across this post so I am learning a lot - thank you everyone. Our insurance has just changed to UHC so I am just starting this process. From what everyone has posted, it seems like I should try to get the pods through our prescription benefits and get them from ADS but looks like this is might not be possible anymore and we might have to try as DME. If you have got them filled as Rx benefits can you share how you did that please??
