Hi I’m insulin dependent type 2 on MDI 6 per day. Trying to get off shots. Medicare has approved omnipod under part D prescription benefits. Can I use omnipod without qualifying for part B DME normally used for pumps? Can the Dr just write a script for pharmacy and I’ll be covered? Does anyone know the guidelines? Thanks in advance
Why don’t you call and ask your insurance carrier as it varies so much between plans. Nancy50
On my pump I had to have Part B to be covered for the pump.
I’ve called Medicare and I can’t get a straight answer out of them as I would be technically going outside their protocol. I’m looking for any type2’s who are using a pump or omnipod how they were able to get approved.
Was it an omnipod?
I think you are asking “can I get pods covered under Part D while not complying with the Part B pump requirements?”. Very interesting question. I would discuss it with Insulet and your pharmacy. Will share my experience but IDK if it will be helpful to your situation. I was using Omnipod about a year before hitting the Medicare age. I do claim under Part B even though they do not pay the bill that Insulet submits
No, it was a Medtronic
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(sorry fat fingered send too soon) Insulet submits a bill which Medicare doesn’t pay. Part B does cover my insulin costs even though they don’t pay for the pump. Can’t tell you the specific form that my Endo submits quarterly to get the Part B coverage. Insulet requests an annual ABN (Advance Beneficiary Notice of Noncoverage) that gives them permission from me to bill Medicare even though they won’t pay and I retain my right to appeal. I believe this extra documentation helps Insulet build the case that Medicare should approve Omnipod as a legit insulin pump. I do not have Part D so Medicare also refuses to pay my pod cost. I have BCBS secondary insurance so that denied claim goes through them. Strangely the PDM is covered under Medicare as a “blood glucose monitor” so there is some coverage for the system. At least it was covered prior to the Part D for pods decision. Have not heard if that changed. I’ve never had any luck calling the Medicare help line. I’ve had great results with Omnipod vs MDI so hope you can find a path that works for you.
How confusing it can be. Nancy50
Your spot on the new part D coverage does it negate part b rules also if I get it will they stop paying for insulin cause it’s a pump. You see my delima I’ll just keep trying to find authorities that have the answers. I’m just so tired of shots and I don’t think it’s right that I should have no options because I’m type 2 thanks for your answers and compassion
So Alley1, were you denied a pump under Medicare? I’m T2. My doc wrote an Rx that the pump is medically necessary. I chose Omnipod (never had any other brand). Medicare pays for my insulin under Part B because I’m using a pump and my Doc submits the quarterly form that I’m using a pump even though Medicare doesn’t consider Omnipod a “pump”… (the lack of logic on this hurts my brain). Since pods are Part D now, I’m guessing that you just need an Rx for pods. Your pharmacist should be able to confirm what they need and Insulet customer service has very good Medicare specialists. If you are able to get a system then it might take some work on your part to get your pharmacy to correctly get the billing for your insulin moved from a Part D rx to a Part B pump supply.
Are you on Part D and do not have Part B? Any Medigap coverage?
I think because Medicare doesn’t consider omnipod a pump I won’t need to change insulin suppliers
I have Medicare b and d
I’ve had an OmniPod for about a decade and am now going on MediCare.
So I called the Medicare 800 number just a few days ago and the
woman I talked to insisted that “MediCare Part B covers OmniPod”,
(yes, B not D) though she did say that I might have to get my endo to
write a “letter of medical necessity” to get them to cover the insulin.
I think that’s what they call a “formulary exception” so I’m willing
to believe that I can make that happen.
But what about the OmniPods themselves?
I’ve read some people saying that MediCare Part B won’t cover
them because “they don’t last long enough”, but when I said to
the MediCare lady that I’d heard the OmniPods need to be covered
with “Part D / drug coverage” she just said that wasn’t true
because “MediCare Part B covers diabetics”.
So have things changed and now I can get coverage without buying
any sort of supplemental plan or even MediCare Part D?
Just want to let you know this Medicare rep is completely wrong Medicare does not consider the omnipod as a pump so it’s covered under part D prescription coverage and since it’s not a “pump” the insulin is also covered by part D. So all your doctor has to do is prescribe it like any other script. I’ve been covered this way for about a month and a half.
Here are details on omnipod website.