With the new $2000 cap on out-of-pocket drug costs, it might be a good time to switch from MDI to an Omnipod. I have been trying to sleuth out answers to my many questions, and I am frustrated by my being unable to answer them all. I am hoping you can bear with me and respond when you can.
You need to replace your Omnipod every 3 days. Do you do this by filling your new pod with insulin from a vial that gets purchased through DME at no cost.
The Omnipod itself gets purchased through Part D, your prescription drub plan, which is capped for out-ot-pocket costs at $2000. Is this correct?
You need to bolus for meals. You need to figure this out? How do you do this? Is it through an app on your iphone or settings that you have to adjust on the Omnipod itself.
How does the Omnipod know how much basal insulin to deliver?
I guess that I would probably get some assistance from my endocrinologists office if I chose the Omnipod, BUT, in trying to determine which drug plan is best it makes a real difference if I select one that covers the Omnipod as opposed to one that doesn’t. And many of the drug plans now choose different basal and bolus insulins for their formulary. As I checked things out, I found the best drug plan for an Omnipod did not offer Fiasp, which is my bolus of choice.
So, you see why I am hoping to gain as much information as possible BEFORE i choose a drug plan or decide if the Omnipod has considerable benefits (I do know that it increases TIR and that is so important).
Many thanks if you have gotten through my list, and I send my appreciation in advance to those of you who can respond.
A grateful Susan
I’ll answer #1: Vial and it goes through Part D drugs. Capped at $35 if your plan has your insulin on formulary. My Part D just dropped Novolog and every single fast acting except generic Humalog. So there’s a consideration. I get insulin at the grocery store and pods through a supplier.
My Part D just did the same. And I checked a few other plans for comparison. They’ve all dropped most of the fast acting insulins AS WELL AS most basal insulins. What’s going on?
To expand on what @Laura_S said for #1 Part B only covers insulin for pumps purchased with Part B. The only ways to get no cost insulin is with a Part B supplement plan or one of the Medicare low income assistance programs.
#3 and #4 Omnipod has a bolus calculator or you can figure out boluses same as you do for MDI. For more info on how the Omnipod works see Laura’s recent tips topic Omnipod 5 Tips - #2 by spdif
#5 I’m not on medicare (yet) but I did a quick search with my zip code and like you none of the plans covered Fiasp. Wild guess but maybe its because Fiasp was on the list of negotiated drug prices? Lumijev is covered by a couple of plans with $100+ monthly premiums. And I hate suggesting changing medications because of insurance.
*When you do your how long to reach the price cap math don’t forget after the first 3 or 6 months your endo is going to change your Omnipod script and do the paperwork to get you one every 2.5 or 2 days so you have spares on hand.
I did plug my current three vials a month, and two day changes/ 90 day pod order values into the plan I researched and it showed all approved. Actually I think I put two vials a month but clinic has me at three right now. And my pharmacy just held up my Sept.refill, stating the fridge was broken and they couldn’t hold my insulin in stock. However, my CDE wrote for three knowing some shortages had been going on with Novolog. Not so sure about the store’s story on that insulin!
AARP UHC (no membership in AARP required) Medicare RX Preferred PDP
From my account on Medicare it looks like everything went through and then on the plan page it even showed me Omnipod 5 and let me add my quantity in. Now I’m on Extra Help so I’m still unsure of prices…
The Omnipod is Nondurable Medical equipment now. You can get it at Walgreens just like your insulin. But, of course, the insulin is sold separately and is not DME or NDME. Omnipod 5 changed in the medical coding from DME to NDME. That’s a big change that confuses some health plans.
You figure this out. That’s a really important piece of this pie, especially if you are running automated algorithm stuff using Omnipod 5. I would work your way up to that by first using the Omnipod in manual mode so you understand how stuff works.
You tell it. You need to know.
They are gonna prescribe Lispro (generic Humalog) for the pump. That should be on the formulary. Are you currently on manual injection or a pump?
