Omnipod 5 coverage with Aetna

Type 1 and LADA
1

Hey all,

I signed up for the Omnipod 5 waiting list and received an email from Insulet on May 2nd telling me it’s now available for prescription for me.

So I had my endo write a prescription to my mail-order pharmacy (CVS/Caremark), but so far Aetna isn’t covering it and it also seems like CVS/Caremark isn’t stocking it. Having my endo file a prior authorization request and we’ll see where it goes.

Anyone else in the same boat? What’s your experience been?

Let’s support one another and help get this covered.

Thanks!
Mark

2

If employer plan, can you check with your employer HR/Benefits group? They may be able to answer if/when the newer podds would be added for coverage, and ensure CVS would be set up to process.

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3

I got the same email and was super excited until I saw that Aetna/Caremark wasn’t covering it yet. Caremark updates their formulary quarterly with the next update scheduled for July. In the meantime, I got a prior authorization submitted and approved. The process was done the same day. Distributors are just getting the product in now so shipping will be delayed. Costco mail order confirmed that they do have them in stock and is processing orders as of today.

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5

i was recently upgraded from mdi to the omnipod dash, and after speaking to a very knowledgeable insulet representative, he informed me that although the 5 was cleared by the fda, the software engineers are having a little trouble with ios, android 12, and right now, they are only available to the clinical trial groups…he said many samsung phones work, but only on android 11, and they wont release the 5 until its fixed…he also said when its fixed, all users will be able to upgrade…if you dont want to wait, the dash works well, and the dash pdm with the calorie king carb counter built in is nice

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thanks for the info, i would except i am starting to get acclimated with androidaps…probably will try to incorporate the watch tomorrow, as i only now discovered you have to build the wearos apk also, but there’s not much to gain for me with the 5, however, the looping apk build, nightscout required stuff can seem overwhelming to many, so im glad the 5 should be out soon…i may call insulet to see if there’s any progress

8

Quick update: Aetna approved my prior authorizations for both the starter kit and the pods.

The bad news is that CVS/Caremark, my mail order pharmacy, still doesn’t have them in stock, so the order is on hold. :man_facepalming:

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Anyone know if Medicare is covering them?

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According to Insulet, yes. You can call Insulet and give them your info and they will check coverage.
Health Insurance Coverage for the Omnipod® 5 Automated Insulin Delivery (AID) System | Omnipod

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Yea I did that 4 days ago when I received the email from them that it was now available. It sent me to their site to upgrade and I filled it out and now it still says ‘Your benefits investigation is still in progress. We will reach out to you by phone or email when your results are ready.’

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I just got an email from them today telling me that I’m approved through Medicare and they are submitting the paperwork to my doc.

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15

I am dealing with the same thing with Aetna insurance! The omnipod rep told me if i start on the dash they can email me and I will be able to update to the 5 right away if/when Aetna decides to cover it. In the meantime I was also told to contact HR at work about the insurance to see if they can make any adjustments for coverage. I’m currently on a tandem pump…I want to be tubing free and waterproof for the summer but i’m having a very hard time letting go of control IQ so i’m hoping the omnipod 5 gets covered soon!

16

If your Tandem pump is still under warranty, most insurance plans won’t cover a new pump.
Hope it works out for you.

My Tandem is oow in about 2 years, and will also be considering switch to Onmipod or whatever else may be available. Glad they are always improving!!

18

I don’t think that’s the case with the Omnipod 5, as it goes through your pharmacy benefits, not DME.

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By the way, I was able to get my Omnipod 5 from Edgepark. Normally my Aetna insurance requires me to go through Caremark, but since Caremark didn’t have any in stock, they made an exception and allowed me to order from a different mail-order-pharmacy.

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Thanks! this is good to know! I feel like everyone I talk to at omnipod has no idea what’s going on so at least I have some suggestions for them. haha

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I have WebTPA which uses Aetna for network docs and Caremark for PBM. I had to get a prior authorization for both the pods and for the starter kit, but I got both virtually immediately. The welcome kit came real quickly but my first OM5 pod order is being delayed until 6/22 because of how recently I got my DASH order of pods.