I am having the same exact issue as Paul. Interestingly though, my co-worker is also on the Omnipod and was denied authorization at first, UHC called her doc's office and the medical assistant yelled at the UHC person and lo and behold it was approved. I am now in the appeal process and am not getting a good feeling. Supposedly there is another patient in my endo's office who had an appeal denied and has been fighting since March.
My concern is I'm in NY and I don't know if I can go through anyone else but Edgepark. I have an appt. with my endo first week of June so maybe I'll try to get a script for another vendor then? OR, switch endos to my co-workers? I really don't know. I can't afford to pay oop. I just reached out to a TV advocate and see if I'll hear back.
My question to Paul is....I know you were concerned about going through another vendor while your appeal was in process, so I guess that didn't have an effect?
I don't know how their medical director can possibly say it's not medically necessary and it's not covered, when it obviously is!
I think it all has something to do with the way they're looking at the coding this year....
The person I'm working with at UHC on my appeal has been very nice and I've reached out to my employer (MasterCard) but so far they are no help at all. To be honest, I'm very dissappointed with them as well...
Hi Lorelei:
I went through this exact situation. I really strongly recommend you contact this person:
Advanced diabetic supplies (Talk to Sheila @ 760-579-7407)
After months of problems she straightened me out within 24 hours. She's a superstar. I had pods in 2 days. She also get me a new PDM.
No problems regarding the other authorization I had in progress and they'll handle everything including contacting your endo for what they need, right away. You don't have to stick with Edgepark--that seems to be something insulet tells people and it's not right.
Hope this helps!
Paul
I have UHC under my husband's plan. I had problems with Optum RX also regarding getting pods. The previous UHC pharmacy, Express Scripts were great. I only had to pay $30 for three boxes but when UHC switched to Optum RX they refused to fill my mail-order prescription for pods. that's when I called them and they told me they don't keep them in stock because I'm the only one that uses them which I find out now by reading this group. They told me that I would have to go through the distributor that I got my monitor from. I've been getting my pods from Edgepark and haven't had any problems. When you have reached your deductible or out-of-pocket expense, they don't cost anything for the year which is really nice because I usually pay $120 for two boxes of pods.
I'm glad that your plan is working out for you. I go through Edgepark for my pods and they will only send me two boxes for two months. If I want three boxes for three months, they have to get approval from my physician and insurance which is a real hassle because it takes EdgePark forever to get approval.
Is there any certain location of Focus Pharmacy that you go through?
Paul,
I don't have long distance. Do you have a 1-800 number that I can call Sheila?
Here you go:
Phone: 1-866-422-4866
And email
sandrin[at]northcoastmed.com
Thank you so much!
Also You can try this Toll Free: 866.416.8088 Ext. 7407
You are very fortunate to have such great coverage. We have UHC with a $4,000 deductible. Once that is met I pay $120 a box. It is unbelievably expensive.
I'm sorry you're having to deal with that. Yes, we are lucky at the moment.
Is your current insurance better than what you'd get from one of the new health exchanges? I have no idea what they cover or if they cover omnipods--I'm sure that's been discussed but I don't know about it.
Oddly enough, I just happened upon your post while googling trying to find coverage for my 8 year old son to start on the OmniPod. We, too, have United Healthcare. It took a while for us to get his CGM covered, but we have had that several months now. We go through Byram Healthcare and that is where United Healthcare directed me to go for the pump coverage. I just got off of the phone with a very nice rep at Byram (they always are) and she is putting the paperwork through for the Prior Authorization that is required. She seems to feel confident things will be covered just as they are with the CGM. The rep at United Healthcare also told me Edgepark was in their network for the pump. GOOD LUCK! The number I call is 800-775-4372.
Glad it’s working out for you.
I use these guys and have been very pleased with them. I have UHC and use a Dexcom G5 and the Omnipod.