OmniPod and Medicare Part D Coverage

I have used the OmniPod since 2009 and love the system. In December, I will need to sign up for Medicare. In talking to Insulet Corporation, I learned that Medicare will cover the OmniPod system under the prescription Part D plan, but that when I apply, I will have to get the Part D carrier to make an exception since OmniPod is not a part of the normal formulary of most companies. I would like to use SilverScript for many reasons, but SilverScript has three plans: Choice, Allure, and Plus. Insulet told me that they have “many patients” who are getting their Pods through SilverScript – having had their exception letters accepted. Great! So I called SilverScript to find out which of the three plans will accept the exception letter to cover the Pods. They refused to give me that information. They said I had to sign up for the plan before they could tell me if the Pods would be covered. That means that if I choose the WRONG plan, I would have to pay about $500 a month from March (when I officially go on Medicare) until October (when I would be eligible to choose a new Part D plan). So my question is this: does anyone using the OmniPod system have SilverScript for coverage? If so, which plan (or plans) will accept the exception letter for coverage? I have to go through Florida for my drug plan, so I can get this covered my Medicare. Thanks to anyone who can help.

Don’t have Omnipod but I believe you are allowed to cancel your Part D drug plan within the first 30 days. So you could choose one and cancel it and try…2 and then …3 or call Silverscript again and tell them thats what you will do if they don’t tell you which plan covers Omnipod. I agree. This rep is being ridiculous. I would call again and a different rep might more than than happy to share that info. You get reps that treat you differently and handle things differently.

Using an Omnipod is still financially disadvantageous for most of us on Medicare compared to a tubed pump. As someone who uses a tubed pump (Tandem X2) and has Basic Medicare with a Medigap plan, my insulin is also covered through Part B DME (durable medical equipment). So both my pump supplies and my insulin are reimbursed 80% by Medicare with my Medigap picking up the remaining 20% and thus no out-of-pocket cost. Because the Omnipod is covered by Part D, it can be much more expensive since both the pods and insulin tend to be Tier 3. Tier 3 and 4 tend to have large deductibles and high copays. I am sorry that you can’t get an answer from SilverScript.

You may find that Facebook will give you more answers than this site. I assume that you might find some info in a Facebook Omnipod group. I belong to a seniors D-group and you might be able to learn things there also. https://www.facebook.com/groups/989708904400922/

Good luck!

I won’t give up my tubeless pump. When I talked to Insulet, they said that they have many patients covered. I am going to try to go back to them to see if I can learn from them WHICH SilverScript plan will cover the OmniPod with an exception letter. I also might try to contact my Endocrinologist to see what plans other patients use. More research is needed. Thanks for your reply, Laddie.

I’ll have to talk to my insurance man to see what he knows about canceling Part D within 30 days. I just do not want to get into a situation where I can get no coverage… or no overage unless I undergo a physical exam. Those never go well for diabetics trying to get insurance coverage. Thanks for your ideas and reply.

Doesn’t Medicare cover the Omnipod pump under Part B? It includes durable medical equipment. Are they saying Omnipods aren’t DME?

No. Omnipods are not DME.

wow, that’s a downer for Omnipod lovers.

Medicare “can” cover Omnipods under Part D. This is per Medicare published “clarification” this past January.

“can” as opposed to “will” as apparently it depends on who provides the Part D coverage.

Tim35, you said, “Medicare “can” cover Omnipods under Part D. This is per Medicare published “clarification” this past January.” That is exactly my question. They will cover OmniPod if I choose the correct SilverScript plan for which Medicare will accept an exemption letter. I just have to figure out WHICH SilverScript plan that is! I was told that OmniPod could not be covered by Part B as DME because the Pods themselves are disposable after three days of use… yet I learned today that the glucose test strips used by us all in glucose meters ARE covered under Part B. What is more disposable than a test strip???

Test strips aren’t DME; it’s the fingerstick meter which is. Test strips are therefore supplies for the FS meter. DME supplies are covered under part B along with the durable bit.

This is why insulin is DME (part B) for tubed pump users but prescription for everyone else; so tubed pumpers get it a lot cheaper (or rather there is better coverage.)

Of course the Omnipod PDM is DME and the pumps are actually supplies for the PDM, along with everything else, but the bureaucrats inside the CMS wouldn’t accept this. I suspect a certain competing pump supplier was lobbying (“paying for” as we say in the normal world) that crazy decision.

For that matter the whole medicare thing is crazy but I’m still six or seven years away from this and, anyway, I only have 36 quarters and I don’t have any earned income.

The “we won’t tell you until you sign up” thing happens outside medicare too. It’s particularly bad in the individual market because the insurance companies won’t reveal the pharmacy costs until January 1 and we have to sign up two weeks before that!

John Bowler

@SherryAnn
For Medicare to consider a system to be DBE, there must be a component of that system which is intended to last a period of time which I recall is generally a 3 year time frame.

Obviously the PDM would appear to fit this definition in terms of the Insulet Omnipod system. The issue is the PDM was coded by CMS (or the PDAC contractor) as E0607 - Home glucose monitor.

Insulet tried to change this coding in 2010 and was denied. Without this - there is no DME and without DME there is no Part B coverage.

I know, Tim35, and the denial just does not make any sense! I hate politics, especially when it gets in the way of simple logic. I suspect you are right that the other pump manufacturers lobbied against the OmniPod getting correctly coded as an insulin pump. I also have the G6 CGM, and that will be covered under Part B because the controller/ monitor is DME, and thus the sensors and the transmitters (supplies) will be covered under Part B also. Medicare will drive me nuts!

Crazy, isn’t it? I keep telling my husband that since his grandfather was born in England and since my great-grandfather was British, maybe we should change our citizenship, move to Canada or England, and see how we fair in their medical systems. They cannot be worse than Medicare.

At the time I left the UK the cost for T1Ds was zero because people with chronic conditions got free prescriptions, even if the prescription was unrelated to the condition! I did have problems getting an adequate supply of test strips, but that was because of the (family) doctor; the doctor has to follow the health system regulations as part of his or her contract and, as non-specialists, individual doctors can be somewhat inflexible.

Anyway I think that is moot now with CGMs; the PM (LADA) is using a Libre and there isn’t any special health system for MPs, unlike here.

I was considering swapping to the Animas Ping this year because I was getting fed up with the Omnipod water proofing and the overall clunkiness of the system. Obviously that got nixed when Animas dropped out of the NA market but that’s not a problem in the EU.

Anyway, Medicare is the best we have - my insurance company cancels their policies at the end of every year and comes up with new ones that I have to apply for. This year they cancelled my HSA eligible plan and wanted to enroll me in on that wasn’t HSA eligible. That could have cost me as much as $3500 extra (depending on my marginal tax rate - US+OR). Fortunately they still had an HSA eligible plan which I had signed up for by 10am on Nov 1.

At least with Medicare the rules are written down, well, except for Part D. Based on the CostCo/EdgePark analysis I posted a couple of days ago:

Killing Part D and putting it into CMS along with allowing the CMS to negotiate prices would drop prices by a factor of about 5.

John Bowler