FUDiabetes

Medicare for Omnipod

I am searching out Medicare coverage to start in January. So far I believe I have found a Medigap supplemental plan that will hopefully be OK for me. But deciding on a Part D prescription drug plan has stalled out due to my confusion.

Once I get on Medicare, I assume that standard Medicare and/or Part G Medigap (which seems to include DME) will cover Dexcom CGM and the Part D prescription drug plan will need to cover insulin and Omnipod. So far I have not found a Part D plan that lists Omnipod as covered…this is getting confusing.

Anybody already gone through this who can point me in the right direction? Thanks in advance

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Not on medicare yet, but this might be helpful.

https://www.omnipod.com/is-omnipod-right-for-me/coverage/medicare

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Yep I saw that, also talked with Insulet Medicare sales folks. The snag I hit was the plan documents for the Part D plans don’t say Omnipod is covered. Called a few and got no answers. It’s all a bit of a blur right now, but the insulin listed on the formulary did not include Fiasp which I use in the pod.

After spending a few hours trying to match up coverage for pods and Fiasp I switched over to the various Med Advantsge plans. I think I found one that will work.

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For some reason it was explained to me that Medicare considers pods disposable so they don’t cover them under durable medical. It can only be under Pharmacy. It doesn’t make sense as Dexcom sensors are disposable but covered under Durable Medical. I have heard Omnipod isn’t trying to pursue changing it. Omnipods have only been covered under Medicare for about 3 years? Someone recently posted they were managing to get the old pods covered under durable medical…but I have a feeling it’s some kind of mistake as no one else has ever been able to, but maybe some plan out there does.

The insulin for pumps is also usually covered under Durable Medical…but from what I understand not for an Omnipod. I am not as clear on that as I use pens to fill my pods and pens are not covered under durable medical.

I have a good supplemental plan and all the pods I need are covered for $40 for a 3 month supply and the same with my insulin, all I need for 3 months for $40, and the Dexcom is free. . So it’s only $80 for a 3 month supply and I have no problem with that to get my preferred items.

Be careful of Advantage plans, I’m sure some people are happy with them…when they cover what you want. But they are notoriously not liked.

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I understand that most people prefer the Supplement plans combined with a Part D plan over the Advantage plans. Could not find any available to me here in WA that seemed to make sense looking at the premiums and coverages. So I ended up enrolling in a HMO (which I have never tried before, I always had PPO insurance) that hopefully covers everything I need in network. Time will tell.

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Good luck @John58 – you are about 3 years ahead of me so I’m looking forward to hearing what you’re finding out.

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Thanks for wishing me luck! For major decisions I usually lean towards keeping all my options open but Medicare does not seem to operate that way. I am locked in with this HMO for a year and will have plenty of opportunities to see how their coverage works out.

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Good time for an update…all the coverage paperwork showed up a few days ago with new insurance cards for both the HMO and Medicare Part A & B. Got started on figuring out how to order prescrips and Dexcom supplies through their system and shooting for a full mail order 90 day supply order in early January. I ended up covered for Dash pods via pharmacy and needing to start an account with ADS for Dexcom supplies.

Only glitch so far is the HMO “assigned me” to a PCP. (My old one, who I had no deep need to continue with is out of network). But for the prescription refills they are going direct to my long term endo who is in network. From the paperwork it looks like I will have to get the new PCP to refer me to my own endo for my next appointment? But not sure about that.

With this transition to Medicare I am also transitioning to 100% mail order refills. So far so good.

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Thanks @John58 - how much do you pay per month? Right now we are in Massachusetts with a “Direct” health plan (non medicare) and paying about $1200/month for 2 people.

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The paperwork states my monthly premium is zero, but I “must continue to pay Medicare Part B premium to Medicare”…still trying to figure out what the Medicare Part B premium will be. Because this is Medicare Advantage, I will have co pays. It appears that there is no deductible.

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My understanding is that if you try to switch to a different MC supplement plan in subsequent years, they could potentially deny or postpone some coverage based on pre-existing conditions.

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Thanks for heads up! The paperwork says there is a safe harbor during this first year, allowing a mid year switch from Advantage to Supplement plan with no penalty. My plan is give everything a try for ordering pods, endo appointment, prescription refills and see how it goes in HMO world. Switching to a Supplement plan will require a broker to help me out, I was unable to fibd anything that looked suitable on my first attempt.

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I’m a Tandem pump and Dexcom user, so don’t have any pod experience. However, my understanding of DME and why pods don’t yet qualify is a follows:

DME typically has to last for 3+ years. For Dexcom, the receiver is the DME and sensors and transmitters are the consumable supplies to make it work. For Tandem and Medtronic pumps, the pump is the DME and cartridges, infusion sets, and insulin are the supplies. And a smart phone is NOT DME.

As a result, an Omnipod does not meet the current definition of DME. Note: I read somewhere that the Dexcom G7 will still have a (maybe optional) receiver, and not just a smart phone, so that it will still qualify as DME under Medicare.

Best of luck! I hope that Insulet can get the definition of DME changed …

John

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I supposed that the Omnipod PDM would be considered DME, and the pods were a consumable supply (like a Dexcom transmitter or a Medtronic reservoir,) sometimes available via a pharmacy benefit; sometimes via a supplier like Byram.

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That’s what I thought, too….but I guess since the PDM is not the pump proper, it’s not?

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I think it has more to do with the regulatory strategy that the company employs. Dexcom had a ton of experience with insurance and probably was looking towards Medicare as a growth vehicle, and so they adopted a strategy that would allow the flexibility to be treated favorably by Medicare when seeking device approval. Omnipod probably underestimated or didn’t think it would be as important, and so they didn’t make the PDM the pump in their filings.

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Marie, Please tell us all what your great Medicare supplement plan is that covers OmniPod so well and what state you live in. I am approaching Medicare and so want to stay with OmniPod but cannot find good coverage here in Virginia!

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@RLS There is no name sorry. It is through my husbands past employer. We paid for monthly insurance through them and when he hit Medicare it automatically went to a supplemental plan they have set up. They cover/covered a certain amount of insurance premiums/costs based on how long he worked for them. it is all through them.

If you work for a large company check with them as several companies have options like that and they are usually pretty good.

Here is a nice thread that explains about Medicare

Of course information changes and a lot of people are interested in who uses what. You could start a thread asking people what they are using for Medicare and how they like it. I have a feeling it would be very useful for a lot of people. Before (and even after) you get Medicare it feels like a very confusing landscape to figure out.

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