Guess I'm Off OmniPod 5

I guess I’ve got to stop using the OmniPod 5 after over a year. I was very happy with the control I was getting (my last A1c was 6.1), and I’m certainly not looking forward to giving myself 6 - 8 injections each day (again), but I went to refill my prescription this morning at Kaiser (I’m on Sr Advantage, so Medicare) and instead of $300 for a 3 month supply of pods, it was $525! That means instead of $1200 per year, OmniPod 5 now costs $2100 at Kaiser Sr. Advantage. Too rich for my blood, never mind what it might go to next year ($3000, $3600?). Too bad - I really liked being on a pump, but before anyone suggests I try one with a tube, I’m not interested. So I’m out!

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What about Eros PODs?

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Never heard of them, but I have an appointment with my Endo the third week in September, so I’ll ask her about them. Unfortunately, I only have 5 Pods left, so I’ll be well into giving myself shots by then. Hope I remember how…

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The Omnipod Eros pods are being discontinued in December. It’s between the Omnipod Dash which is similar to the Eros or the Omnipod 5. The 5 is the Omnipod loop system. You could do DIY loop with the Dash pods.

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Yes. I have quite a few Eros POD unopened boxes I could send to someone who needed them. I think I have the PDM somewhere also (which would be needed unless you loop with Omniloop, then you’d need your phone and a Riley Link with zeros PODs). They are being discontinued (or have been) but I was offering to send my remaining supply if you had nothing. Eros with PDM works enable you to pump instead of MDI.

Send me a PM if this if something you are interested in.

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Yep, same for me! I have a bunch of the old ones, if you need some.

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I guess no one is surprised that my Medicare co-pay for OmniPod 5 almost doubled! Any other OmniPod 5 users experience this? I don’t see how they can expect to sell these things with such a drastic price increase, especially if they can’t even get them working with iPhones after over a year, never mind how old the Android phones that work have to be. Who knows how long before they work with Dexcom’s G7. Will that new version go back to the beginning for compatible phones? Wouldn’t surprise me. I gotta say - I thought the OmniPod 5 was awesome when I started, but their development progress has been glacial!

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@bggale I don’t use O5, so may not understand the situation sufficiently. I just did a quick search and found several references that O5 is covered by Medicare Part D, though none of the articles indicated a % coverage. Do you have a part D plan or did the coverage rules for Part D change?

Either way, both @Eric and @ClaudnDaye can apparently send you some pods to cover the period prior to your Endo appt for a recommendation (Note: edited). Can you take advantage of their offers for an interim solution? You can use DM to contact either by clicking on their names in their posts (if you didn’t know that).

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I’ve bern getting the Om5 pods on Medicare Part D with a Cigna Part D plan. They have not raised the copay as far as I can tell. @bggale : Maybe the “donut hole” coverage gap caused your co pays to double. It’s a little complicated to calculate how the donut hole hits Part D co pays but is unavoidable.

I agree with you about Insulets lack of improvements since the Om5 came out. I am probably switching to the Tandem Mobi when it is available next year, hoping their tech is more up to date.

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Correction: we aren’t offering O5’s. We are offering the Eros PODs which are the old style PODs before Dash and O5s.

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Sorry for my error…I must have mis-read/understood. WIll look closer in future!

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Yep, I have only used the old ones and the Dash.

I have never used the O5. And I hope I never will have to.

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@TomH He has an advantage plan so it can be different than straightforward Medicare coverage. On the price raising, it could be Insulet but it very well could be his Kaiser plan raising the price.

In our case our insurance company reviews everything once a year in January and Omnipods falls under pharmacy at a set price the same as insulin or most drugs. I know we got a notice last December that costs of the plan had gone up, but our pharmacy copay wasn’t changed and the insurance cost wasn’t raised because of our Gap insurance still covered it. It’s through my husbands past employer.

The O5 is the only loop system that Omnipod has. Eros and Dash aren’t, so I suppose it matters if he is trying to go for the loop system or the tubeless pump part. @Eric and @ClaudnDaye are offering the pods for Eros which if he just wants the tubeless part of Omnipod will work. But if he wants the looping part he either has to DIY Loop on Omnipod or switch to a different tubed pump which is covered under Part B. But he has an advantage plan and he still might have a copay or limits on which pump he can get. But I think tubed pumps are cheaper for supplies?

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Or maybe he just moved into the Doughnut Hole stage of reimbursement. When that happened to me my cost of pods went way way up.

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That’s a real possibility

I don’t know enough about the donut hole. Our gap Ins covers that. That could be it. So he could be at the start of the donut hole? I believe then you have to pay everything for your meds from the gap of $4020 to $6350 spent?

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I don’t understand that happening mid-year (well, indeed, third quarter).

Something changed but probably not what you think, or expect. Retail prices are set in Q4 of the previous year and Medicare is required to follow retail prices so there shouldn’t be a jump during the year.

I suggest asking customer service. Something like, “I’ve been getting this drug all year but I walked in to pick it up today and was charged an extra $225, I can’t afford to pay this again and I really will die if I can’t get it, please tell me what happened.” My wife is great at this, I just spit vitriol.

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I called Kaiser Member Services, and all they could tell me is it might be the donut hole everyone is talking about, or the price might have gone up. I will just go back to injections until I can discuss this with my Endo, although they typically don’t know anything about pricing, co-pays or policies. I suspect I’m just sol.
Just in case - tomorrow I’m going back to the pharmacy to ask them to actually show me what that $525 is buying. I have a feeling it might be for the OmniPod Starter kit, with 3 months worth of pods, plus some extras, plus a controller. Since my Endo never removed the starter kit from my online prescription refill list, and it has the same prescription number as just the pods, it’s possible I clicked the wrong item to refill. I nearly did that the last time I refilled my pods.
I thought this might be the case Friday, but when I asked the pharmacist if the prescription number was the same as one I had photographed on my pods refill, she said it was. I forgot the starter kit also has that number, which is why I asked my Endo to please remove it from my refill list. Member Services also could only verify the prescription number I refilled. The real bad news is that if that is the case, the two variations of pod refills won’t show up in my list again until 3 months have elapsed, and they may never show up again as long as I keep getting notified I have a refill to pick up. I’m also not looking forward to the over 1 hour round trip to the only Kaiser pharmacy around here where we can get OmniPods. Again - I fear I am sol. Oh well…

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Well for perspective or cost comparison…I hit that donut hole earlier this year. A 30 day refill for me is 3 boxes, 15 Om5 pods. Copay us $221. That is using a Part D prescription drug plan from Cigna (which I pay about $100 per month for). So all in all at $525 for a 3 month refill (assuming you get 6 boxes for 3 months) your copays are comparable to the “going price” for pods on Medicare.

But it seems odd that they can’t tell you what is in the 3-month refill, starter kit or 30 pods.

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Choice of Medicare plans for next year will be coming shortly. Reassess your options then. Your current plan should have been able to give a better answer to your question. Try escalating & mention this may drive you to give them the heave-ho. Dr offices are not able to keep up with details of all insurance coverages. Insulet customer help line or local sales rep might be able to help also.

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