I haven’t been on this site since my diagnosis at least 5-6 years ago, it’s nice to see some of the faces I used to communicate with are still on here and the forum is still up and running! I learned so many things here.
I had to change my marketplace insurance this year, due to Aetna backing out. Unfortunately, my HBCBS insurance isn’t as comparable as they marketed it, and for the first time in 5 years I will have to come off of my Omnipod pump and go back onto pens. I’m just reaching out on here to ask what others experiences were with this, whether it be pump breaks or a similar situation that forced them off. Just so I know what to look forward to. I believe I have one pod left aside from the one I’m currently wearing, any info shared is appreciated.
What POD do you use and would you accept an immediate supply (If you use the Dash PODs), if I were willing to ship you some, to hold you over for a couple months until you sort through the info?
I believe MDI is not medically equivalent to pump therapy, therefore I suspect you may have some choice. The problem is finding out what it is… Omnipods were, originally, “DME” - durable medical equipment - but because of MediCare that didn’t work and Insulet switched to a prescription-primarily model. As a result my ACA insurance switched to letting me get the 'pod from Walmart; I waved goodbye to EdgePark and breeved and enormous sigh of relief.
Check the formulary of your new provider. It is best to do this with the telephone, the POTS; their web may lie. Possibilities for prescription pumps seem, ATM, to be the 'pods and twiist so you may be able to swap to twiist.
Check your endo; endos should know what to do. GPs certainly not.
Insulin pump therapy is an accepted, important and in many cases essential part of treatment for diabetes. If your insurance company doesn’t think you need it they can put you on “step therapy” (the medical equivalent of a performance improvement plan) until you prove that you do (easy.) However I don’t think they will; that would be utterly dumb on their part. They just want you to give up but if you don’t they’ll fold given an informed and capable endo in your hand. Medical poker.
the first answer is to go to your provider and ask them to write an appeal based on necessity. Continue to appeal as long as possible, plan on 2 or so denials at least before you make some headway. Appeal, Appeal Appeal.
I’m with @Rphil2 on this. You need a doctor who will appeal. That’s part of the process of obtaining pump approval. If they aren’t doing that, then they are saying they don’t have time. You need a new doc. The doc writes a, “letter of medical necessity.”
I know my own comments sometimes forget some folks live in an area without multiple choices for a doc, let alone an Endo or CDE. For those folks, it may be the local doc won’t go the step of preparing an appeal for you, but may sign one prepared by the T1/T2 person involved. It means those folks may need to become aware of the process and requirements of your insurance and take the time to prep the form/format for the doc or advise them where/how to do it. Not what folks already at a disadvantage want, but its probably doable. Again, this involves finding out the process and talking with the doc or finding out who in the doc’s office handles such things. I live in an urban area of DC but recently had to get a new Pre-Auth done for my pump and CGM (didn’t know both had PAs done originally or if it was a change). Called the pharmacy/insurance I use, found the CGM was good until 2099 (seems dumb to even have a PA), but the pump PA expired every 2-years (go figure!). Looked up the process and forms needed, used the online system to let my doc’s office know. They handled it their way rather than me having to do it.
I’ve been on the 5 pods, I’m not even sure if my Dash PDM would still turn on. I could check in on that when I get home from work tonight at midnight. The offer is greatly appreciated.
I’ll look into calling Horizon tomorrow, but the reps seem to have no idea how to explain anything to me other than the fact that it should be covered under my pharmacy plan, and then make me Prime Therapeutics problem - who seemingly have less answers other than the fact that they haven’t heard back from my Endo in regards to PA auths that I requested a roll-out on back in January.
Marketplace insurance has gotten exceedingly difficult to work with and cover things this year and I am very overwhelmed. So, sad to say, they’re currently winning. They want $568 for a month supply of Omni5 pods and even with the copay assistance program through Insulet, I’m still looking at 468/mo and that’s just for my pods. My sensors (with insurance, as I am currently outside of a $2,100 deductible) are a whopping $245/mo - I just found a g7 coupon and I will be paying $369 for a 90 day supply (HALLELUJAH) but it’s like the blind leading the blind over here.
That’s all the answer they need because it’s a new insurer. If they didn’t get the paperwork they ignore it. It’s quite possible that your endo faxed the paperwork to your old insurer whatever you told them; you spoke to a receptionist, the receptionist spoke to the nurse, the nurse spoke to the doctor and you were apparently having trouble with your back, etc.
Many other “entertaining” possibilities exist. If the Prime blames the endo the only choice is to talk to the endo, or rather his/her receptionist.
I can’t work out what sort of ACA plan you are on or how the Omnipod is covered. It sounds like it is covered as DME (Durable Medical Equipment) not as a “Pharmacy Benefit”. The formulary only counts for “Pharmacy Benefit”, “DME” is normally at the doc’s discretion; the doc may have to justify an insulin pump (the PA) but it shouldn’t be manufacturer specific these days.
However if the Horizon plan is an HMO I believe many other restrictions are possible possibly including restricting the pharmacy you use to a company one. I don’t know, I’ve always been covered by PPOs.
If the Omnipod is covered as a Pharmacy Benefit and you are on a PPO then it should be possible to get it from any retail pharmacy. That’s a good way of discovering the truth; you might get another lie but it will be a different one.
That seems reasonable for private (not employer) insurance. It’s probably reasonable for cheap (to the employer) employer insurance too. For much of my time on the ACA it was $300/month. I didn’t get any on ACA last year (when I went on to Medicare in April) but in March 2024 I paid $1637.68 for 90 days with a nominal cash price of $2113.14. So that’s $545.89/month (cash $704.38). The rebates weren’t worth the effort because I also use a CGM so I hit the out-of-pocket maximum; about $7000 so $590/month in 2024.
That’s good but always bear in mind that the OOPMax is close, particularly with a CGM. This year it is at most $883.34/month because it’s $10,600. If you pay more for a better plan you typically end up just paying up-front (in the premiums) and Bronze plans often have a lower OOPMax than the mandatory limit. Premium credit is limited to the plan cost per year, so you want a plan close to that cost or you lose some credit but for most people the cheapest plan still gets the maximum credit… Something to think about in December.
We are retired and covered by my husbands past employer. They switched who they have providing pharmacy benefits. They want people to switch to generics and have dropped a lot of the covered drugs to save money. However, you can appeal, and an endo is more likely to know the ropes to do so. In my case Omnipods were dropped, Afrezza was dropped and Humalog. Gees, everything I use. In my case the employer had set up a back up plan for drugs that wouldn’t be covered. But you have to go through the Pharmacy providers appeal process before they will go through their process. And dropping Omnipod was a surprise since it is one of the most popular pumps in the US, Humalog is also high on the list in popularity.
So I asked my endo to submit new prescriptions, of which they were turned down. They provide a list of alternatives to use instead of which they clearly stated there is none except for the Humalog, but they don’t cover that either. So then my endo submitted the appeals, and all of them, even the Afrezza was okayed.
I am on Medicare with a gap type insurance from my husbands ex employer who also provides the pharmacy benefits. So my experience could differ from yours. But before retirement I had to appeal for Humalog a couple of times and as long as I had tried the alternatives, and they weren’t as good, they were then approved at a higher tiered cost. Omnipod is unique because it is supplied by pharmacy and I’m not sure you will win, except that you have the history of using it successfully. So it might be worth trying, if you try, this is what’s working for my patient and she needs a patch pump because… In my case I told her that is the only one that will keep giving me insulin while I swim which a tubed pump won’t, and that is the only exercise I can do because of my back. I also gave her a couple of other reasons to use if she needed. I don’t know if she used any of it. All I know is it got approved for the year. The other alternative is switching to a different pump that would be covered under your DME coverage. Pumps are really important for type 1’s for control so they should cover at least one.
That’s your PBM - Pharmacy Benefit Manager. Those assholes. Unbelievable. They are not allowed, by law, to make medical decisions.
I think you should write this entire experience down, with all your hardships, and submit it as public comment to FTC and DOJ. I will help if you start recounting your experience in writing. I’m furious.
An Omnipod is stand equipment. What state are you in? We have a federal bill for this. It’s not passed yet.
I would be willing to try another pump, but the Omnipod is ideal for me because it has no tubing - and I am a menace on my own two feet. I have marketplace insurance through the state of NJ and they really seemed to just crack the whip on everything that’s over $200 in cost, it’s all falling on the backend of patient copays and it’s a very scary time for us indeed. I’m glad you were able to get all of this worked out, it’s unfortunate how aggressive we have to get just for them to pay for our needs.
I’m in NJ. That sounds like something I’ll be interested in tbh. I digress, I confirmed that they faxed my PA requests to the right fax number after I followed up with them in late January/early February. My Endo gave me sensors to hold me over until I have enough money to pay for my 90 day supply. When I was in their office, I asked if they could check on the status of my prior authorizations. They had no pending PAs.
When I called Prime, they found nothing in their system either. I got stern with her when I asked “could you tell me why that is?” dead silence
I informed her that she should probably have in her notes from that time that I confirmed the proper fax number for my Dr’s office and I’m at a loss as to how they still hadn’t received any paperwork from them. I stayed on the phone with her to confirm they sent it, confirmed with my endo’s office and then proceeded to have her note to expedite the Omnipod PA. It really frustrates me that you have to parent these companies just to get them to do their jobs smh. I’ll be calling them every day until I have an outcome.
I can’t speak for Marie, but a couple of years ago my plan switched and Novolog was preferred. I found out through that process that my diabetes thinks insulin asparts are water and I can only use insulin lispros as short acting. Funny how weird our bodies can be about that stuff.
That is a tough switch. It can take a little time to adjust, but most people find their rhythm again. It just tends to be a bit more hands on at first.
They cover Novolog and Fiasp. I have tried Novolog about 3 different times through the years and it takes longer to work for me, so I just don’t prefer it. Forget Fiasp, that was like water by the third injection. The first shot worked great, by the third it wasn’t working at all. At least they distinguish insulin lispro from insulin aspart now. In their suggestions of substitutions they list Admelog, which is a insulin lispro, but I thought it was amusing they list that as a substitution and don’t cover that either. The other two, Dash Pods and Afrezza were listed as having no substitutions.
The same with me, I have always felt I would be horrible with a tubed pump and the tubes. I was always the person catching my earrings, (I have always refused to get pierced ears because of that) Glasses getting caught and squished (so I used cheap readers at work) anything that could get pulled off would lol. So until my endo showed me her omnipod did I decide to get a pump.
I really prefer NovoLog in the pump. Humalog is the same for me when injecting with a syringe, but in the pump it does not last 3 days for me!
Last year my insurance did not cover NovoLog. I switched insurance this year, just to stock up on Novo for the year. I am getting a bunch of it. But my insurance this year really sucks.
So next year I am going back to the other insurance, which does not cover Novo.
Imagine 2 people who have known each other for many years. Say they met on some random diabetes forum.
Suppose one of them can’t get Humalog through their insurance, which they prefer. The other person can’t get NovoLog, which they greatly prefer
If only they could figure something out… But gosh, I just don’t know. I mean, what in the world could they do that would help them both equally?!?
