What insurance is most OmniPod friendly?

Diabetes Technology Insulin Pumps
21

I live in Florida but am currently covered by UMR (United Health) through my former employer's insurance plan in Wisconsin. Pods are covered for me 100% once I meet my deductible. As others have said, though, your actual costs will be totally dependent on WHICH plan you have.

I know that another member of this forum who lives in Florida is on Medicare and uses Florida Blue which I assume is Blue Cross/ Blue Shield. You might want to contact them since I know she gets her Pods covered through them. Good luck. With insurance companies, sadly, you will need it!

22

Yes, but so far as the *original* question is concerned it really *is* as simple as this. It used to be very difficult to find out how much it would cost *us* T1Ds, but because the ACA limited the options for insurance companies on non-covered items, limits and, most important, using different totals for the various limits now it comes down to simple arithmetic.

I do not think the political argument is helpful for the OP or for most other people on tud; I do actually agree with you, but if we start to discuss it we will argue pointlessly.

23

IMHO, BCBS is the way to go. If you value your life, avoid Kaiser Permanente at all costs.

24

Hello, Iā€™m reviving this old thread because open enrollment has begun! Iā€™ve had an individual health plan through the marketplace for the first time this year (in Maryland) and it was a bit of a shock with all the out-of-pocket expenses. Navigating insurance costs is so confusing and now Iā€™m trying to figure out what will be the best for me with my current combination of costs.

Also, I wanted to say THANK YOU to whoever mentioned Freestyle Promise and Mini Pharmacy. I will definitely look into this to save money on my strips.

I will share my info to hopefully help anyone else who is comparing costs. I would love to hear from anyone else who is willing to share specifics. I may try to call a broker to help me decide, but as of now, I have a spreadsheet going!

current plan: My CIGNA Health Flex 1250 (discontinued after this year)

out of pocket costs for the Omnipod:
Freestyle Test Strips: $60 per one-month supply
Humalog insulin: $30 or $35 per one-month supply

Pods: $83.30 per box of 10 pods (20% of billed cost - $416.50)
They bill through CareCentrix. I donā€™t know whether the billed cost would be different with other insurers. (This is after the $1,250 deductible is paid out of pocket, of course.)

I also got the BILLING CODES for anyone who wants to check with a potential insurer regarding coverage. In general, the PDM and pods are considered durable medical equipment.
PDM: E0784
pods: A9274

Thanks and Iā€™d love to hear from you, especially anyone who is self-employed. : )

1 Like
25

We have you UHC in Florida. We pay $33 for a three month supply of Omni pod pumps. We also have the dexcom and pay $11 a month for supplies. It is covered under the prescription plan so you have to make sure that the outsource for Omni pod through UHC which is diabetes specialty center files the claim that way. However it doesnā€™t cover the Omni pump cost of $250 a month for the receiver

26

Hi guys!! Iā€™m posting more info about what I found out! (Copied from another post reply.)

Hi everyone! I have been doing research on the different plans on the Marketplace in Maryland for the last several weeks. Itā€™s all very complicated!

If anyone is in Maryland, I did find that there are three plans here that actually have a special diabetes plan. They are:

  • Evergreen Health Select Platinum 250

  • Evergreen Health Select Gold 1100

  • Evergreen Health Select Silver 4400
    (only the plans that have ā€œSelectā€ in the name offer this benefit)

They are all HMOs, but donā€™t require a referral to see a specialist. I checked and my doctors are actually all in the plan. It pays to be local, I guess! You really canā€™t find any info about the plan online, but their customer service is very helpful. Here are the special benefits:

  • 0 copay for preferred brand test strips

  • 0 coinsurance for lab services like A1c (2x/yr)

  • 0 copay for preferred generics (insulin) or 50% cost reduction for preferred brand drugs

  • 0 copay for diabetes management - visits to primary care physician, endocrinologist, annual eye exam, podiatrist

I also made a crazy spreadsheet of like 30 different plans comparing how much I would pay out of pocket. My specific focus is the Omnipod. Personally, I chose to go with the Platinum 250 plan because of all the Omnipod out of pocket. Also, itā€™s only 10% coinsurance for durable medical equipment. Omnipod/Insulet is in-network.

More info:
ļ»æwww.evergreenmd.org or 410-844-0701

Message me if youā€™re interested in my crazy spreadsheet! Happy insurance selecting, my friends!

2 Likes
27

My husband is retiring in a few months and we need to purchase our own insurance until medicare kicks in. Youā€™re correct in that you can call any insurance and they will read their coverage of pumps from their written books but they usually wonā€™t try or cannot find specifics in that it includes covers Omnipod. The cost will be whatever your copay is based on whatever insurance you choose.

The problem seems to be that pumps are covered under DME but the code for the pod is a ā€œdisposableā€ code which needs to go to prescription but prescriptions doesnā€™t cover pumps! Itā€™s a mess, vicious circle and all do to coding. I was told to try United Healthcare (michigan) but my Doctors arenā€™t in the network. It looks like BCBS is the only one that covers our Docs. Iā€™m calling tomorrow to see if the pod is included in their coverage. I keep being told that all the HAP, BCBS, United, whatever will either cover or not cover and if one program covers then all in that one will cover itā€™s the amount you pay monthly, deductibles, and co-pays that changes but canā€™t verify this.

28

Barbraan,
Iā€™ve been retired as of 12/32/14. BCBS (thru employer) was wonderful. They paid in FULL 100% for my insulin, test strips & OmniPods. When they changed to United Healthcare they paid 80%.
Now that Iā€™m retired and on Medicare and united Healthcare Plan N I was told by insurance broker that pods would be covered with a note from my doctor. Sadly, thatā€™s not the case.
I appealed medicareā€™s decision and lost. Will soon be wkg on 2nd appeal.
Good luck to you!
Am hoping for a 2016 miracle!

29

Oh, I live in New York.

30

Not in New York but United Healthcare covered my Pods when I was on the Omnipod over the summer - and they covered it through the pharmacy prescription, not DME. They gave me a problem covering the Animas Vibe PUMP when I tried; however, they have covered the supplies for it without a problem. Once Medicare kicks in, of course, all bets are offā€¦

31

Itā€™s just such a complicated questionā€¦ Itā€™s rarely a matter of ā€œinsurer Aā€ covers this and ā€œinsurer bā€ doesnā€™t anymoreā€¦ In many cases each of these insurance firms process thousands of different policy arrangements for millions of different policy holdersā€¦ Creating an incomprehensible ratā€™s nest of BS where basic questions become unanswerable and basic services uncertainā€¦

32

Iā€™m dreading medicare. There is a bill in congress trying to get medicare to cover the CGMā€™s so write to youā€™re congress person! I have multiple times.

33

Just started our son on the pod (had used pens since being diagnosed). Talked to Insulet and they contacted our insurance and told us how much it would cost. Insulet said the startup cost would be $800 and we got our first bill for $913. Supplies were supposed to be $400/quarter and now we find out itā€™s $646. Donā€™t trust the estimates from Insulet and good luck getting the info out of our insurance company. Itā€™s truly ridiculousā€¦

34

I signed up on this site just so I could ask this question!

Iā€™m in San Diego and my wife has diabetes. Sheā€™s been using an omnipod for years and I fear that if she had to switch to something else, she may actually commit suicide! Really. She was close before we found the omnipod.

I currently have United Health Care through my work but now that Iā€™m layed off, Iā€™m wondering if maybe I can get my own insurance. I have a lot of investments and could possibly just retire.

Looking at the ā€œCovered Californiaā€ site, I see I could get Sharp, Kaiser, Healthnet, Kaiser, and Anthem. I know that Medicare doesnā€™t cover omnipod, so Iā€™m hoping to avoid using that (once I turn 65, currently Iā€™m 57). I think I read that Anthem isnā€™t that great re. coverage either.

Iā€™m wondering about Healthnet, Kaiser, and Sharp. Any info?

35

Hi Raj12,

Iā€™m not sure about other companies and states (Iā€™m in FL) but I found that United Healthcare was the most friendly (based on co-pay and premiums). It is provided through the health care marketplace, though, the plan my husband has will no longer be offered next year so Iā€™ll have to start looking again soon (yayšŸ˜’). It took hours upon hours of research and calling all insurance companies multiple times to talk to different CSRs.

What I ended up doing was finding out the medical code for medical devices and then I used that code when calling the different insurances available here to get specific coverage info (co-pay/% covered) on medical devices.

From this experience I learned that:

  1. The people you will be talking to at the insurance companies have no clue what an OmniPod is (thatā€™s why you need to ask them about medical devices in general). So, itā€™s not about whether or not they cover the OmniPod, itā€™s about whether or not (or to what extent) they cover medical devices.

  2. It has been my experience that, if your doctor writes the correct prescription, the insurance will cover it (to the extent that they cover all medical devices). With the initial prescription our insurance did require an additional form from the doctorā€¦not sure what that was calledā€¦but it basically was saying, yes, this is a medical necessity.

One more thingā€¦if your wife doesnā€™t already have itā€¦she should check out the Dexcom. My husband has had it for a year and it has been absolutely life changing. He uses both devices together and his insurance covers both!

It takes lots of work but there is hope!

1 Like
36

Raj12, I am in San Diego, over 50 but under 60, self-employed, and we just switched this year ā€“ the year of my T1 diagnosis ā€“ from a private grandfathered Anthem BC plan (also offered by Covered CA) to a BS Bronze PPO plan with smaller premiums.

Our premiums with Anthem were increasing 20-25% per year, until we were paying more for our plan than we were our mortgage.

We bit the bullet, said goodbye to our everything is covered plan, and are paying more per doctor visit, but less for labs and about the same for generic meds.

So the formulary for BS does not cover my treatment, Tresiba. After we switched, I was diagnosed. But I looked into the Anthem formulary too, and Tresiba is not covered there, either. So I am lucky to have an endo who gives samples.

I can look to see if BS covers OmniPod but it may take me a few days. Stuff I must attend to right now in my life.

My suggestion is to call the companies you are interested in, and ask for their formulary list. It will tell you which tier your supplies fall in, and that will give you your answer.

However, I must say emphatically:

Stay Away From KAISER!!!

Personal experiences of a non-diabetic friend of family cause me to say this.

One reason we went with BS PPO is because many of our doctors are Scripps-based. Scripps Clinics ONLY accept BS PPOs. No other plans from Covered CA will be accepted at Scripps.

Best of luck, and best of health to both your wife and you!

37

I donā€™t know about omnipod/diabetes care, but I had Kaiser for many years with no problems. Of course, I also have no special medical needs, so maybe thatā€™s worth considering.

I thought I had heard that Blue Shield didnā€™t like omnipods but I could be wrong. I can tell Iā€™m due for learning A LOT about the medical system! Iā€™ll have to write up a web page with my findings.

Thanks for the info!

38

JessK: You mention that you found the medical code for medical devices. How did you find that? Are you talking about the code for ā€œdurable medical equipmentā€? But Iā€™ve heard that while some insurers consider omnipods to be durable medical, others (such as Medicare) consider them under disposable. So, then we come back to trying to figure out how the company will categorize them. It would seem that the only way to know that is to ask the company how they categorize them, at which point youā€™re back to asking about omnipods, specially.

39

Yes, Iā€™m talking about durable medical equipment. Honestly, I googled it to get the answer and then checked it with a doctor friend to make sure I had the correct code. As for durable vs. disposable, as I said, this was just my experience, I am by no means and expert or professional and Iā€™ve never dealt with Medicare so I canā€™t speak to that. I really wish we had some kind of diabetes advocacy group that helped us navigate through all this medical mess.

40

I found Omnipoda one month supply $249
Iā€™m on Medicare and if I were to buy another plan it would probably
Be way more. The reviews are excellent on Amazon they take returns for defective sensors etc. they are brand new. Iā€™m a relieved.