Don’t want to distract from the issue you’re speaking about, but I’m interested in the Omnipod 5.
It’s now approved and available in Canada and in my province too. But it is rather costly - think I will stay on Dash until they bring the price down more. Too much money.
But did you find it to be really good? It just seems to be more expensive rather than effective but I haven’t checked it out yet. Thanks!
If your PBM is ExpressScripts, you can sue them for price gouging & racketeering. BLB&G Announces Filing of Racketeering Class Action Against Express Scripts | Bernstein Litowitz Berger & Grossmann LLP
This is a followup on the FTC’s ruling that they were price fixing.
If you want to write to the government about how miserable your experience of the medical system is, one option is to write to DOJ and FTC. They have extended their deadline until May 21, 2026 at 11:59 PM EDT.
Here’s where you can submit perspectives on the market (and it’s many failures) and antitrust regulation to DOJ and FTC, if you want. It’s meant to be “not industry specific,” but it’s OK to give specific personal experience from industry. Link to submit is here: Federal Trade Commission and Department of Justice Seek Public Comment for Guidance on Business Collaborations | Federal Trade Commission
You can read comments that were already submitted here: https://www.regulations.gov/document/ATR-2026-0001-0001/comment
They are specifically asking how to rewrite rules that define “collaboration” in industry and how that differs from monopoly behavior. There’s a month left to submit. Comments are due by Apr 24, 2026 at 11:59 PM EDT. These are the previous rules that were deleted: https://www.ftc.gov/sites/default/files/documents/public_events/joint-venture-hearings-antitrust-guidelines-collaboration-among-competitors/ftcdojguidelines-2.pdf But I don’t think you have to adhere strictly to that. The agencies want to hear from citizens about thier experiences with medicine because they have setup comittees to try and solve some of these problems.
Here’s what I wrote, but it’s not posted publicly yet. They are still reading it. It’s long, but you can scan it. VERY open ended request for public comment from DOJ & FTC - #20 by mohe0001
Here’s what the pharmacists wrote: Regulations.gov
There’s a recently reactivated topic here which might help:
Changing from the Dash to the O5 is a major change; it’s going from a traditional pump with CGM to a full AIDS (Artificial Insulin Delivery System). That’s a different approach for us, a big deal. There’s lots of discussion here and a lot of wisdom; the above post dates from 2023, if you follow it through you will learn a lot of the differences between Dash and other traditional systems and the O5 and other AIDSes.
In reply to New insurance is sending me back to MDI after 5yrs on Omnipod - #22 by mohe0001 :
The thing is that Prime is not just a PBM in this context, it’s the above and more:
Ok, that’s the marketing, but it does explain the business model too. Here’s their prescription offering:
I don’t believe that it’s “PBMs vs us” any longer - I’m not in this business but I’ve got the impression that the move is towards giant service providers that the insurance companies can use to outsource their services. So transiting from Aetna, which already provides that kind of outsourcing, to a different insurance company which does not is, perhaps, the change.
I don’t know; certainly your ballpark not mine.
Thanks so much for your response. I find Dash to be a really simple and mostly efficient insulin delivery system - O5 apparently takes over control and you have to let it be (someone who tried it told me that!). As probably like many T1Ds, I’m a bit obsessive about controlling my blood sugars so that makes me think the O5 might not be for me. Will have to wait and see.
Welcome back, that is a big switch after being on a pump for so long. A lot of people mention it takes a bit to get used to the extra timing and decisions again, but it usually settles with time. It can feel like more effort at first, but some also say it helps them notice patterns differently. Curious if anyone here has tips that made the transition easier?
I’m also on Dash. Omnipod 5 has a manual setting so you can run it just like Dash. They don’t force you to use the automation. I would encourage you to NOT upgrade into a new sensor model AND AID at the same time. Try to stagger that so you aren’t troublshooting hardware & software at the same time. That sucks.
Heads up that we need to upgrade our G6 by this summer.
No worries, I love a good sidebar! I’m a LADA diagnosis - so I became a t1 at around age 30-32. My insulin sensitivity is still pretty decent, so at night I would have hypos and I would have to wake up and treat - this was an issue I was hoping would get resolved when I switched to the Omnipod Dash system. It didn’t, and after a year or so of trying to finagle my basal rate… I found I was covered for the 5. The automated mode is perfect for sleep for me, as it catches me while I’m dipping down and it’ll give me a bolus as soon as I start to rise in the morning. I switch back and forth between manual and automated mode - but it does make my life and sleep a lot easier.
Unfortunately, I can’t find any connections between ExpressScripts and Prime Therapeutics. But this is helpful knowledge, and I may consider discussing this with them when I call tomorrow to raise hell. They’re basically forcing medical decisions on me via outlandish copayments. After them stating to my Endo that I DON’T need a prior authorization for either of my tech, they confirmed with me I did. When they approved the PA, my pharmacy basically told me that they’re not paying a single dollar. They may be able to hide within my OOP deductible, but they’re going to hear from me and have me exhaust every possible resource until I move back on to pens. I’m livid about this, I haven’t had an experience like this with my tech in the entirety of the 6 years I’ve been t1. To have them outright tell me that I need to go MDI because there’s “nothing” they can do about my coverage, is simply something I will fight until I can’t about.
Thanks so much for your feedback. It sounds like the O5 works on you very well!
Will look at it more carefully and then see if I can afford it here - Alberta, we have a nasty leader here who doesn’t enable any federal programs. So unfortunate.
Both ExpressScripts and Prime are PBMs. The government only went after the 3 largest PBMs in their recent efforts (Cigna/CVS, Optum from UnitedHealth, and ExpressScripts). No one thought they could even succeed at that, but so far so good.
Here’s a link to the pharmacists recent work on PBMs. Some of them are in DC as we speak. https://www.youtube.com/watch?v=k0bcWlI4ht4
Here’s a link to the work by the diabetics (including people from TUD) FTC Sues Prescription Drug Middlemen for Artificially Inflating Insulin Drug Prices | Federal Trade Commission
I’m trying to get a doctor to submit right now and I notice the gov’s website is throwing an error.
@Necroplasm - PLEASE look into Omnipod’s copay card / financial assistance program. These programs are straightforward to apply for and will cover a huge amount of your copay. You’d be surprised how many drugs that we use have coverage with these! (Omnipod, insulin, migraine meds, etc.). Good luck with all of this – so sorry you are dealing with it. You should NOT have to go back to MDI - keep up the good fight!
@Necroplasm Sometimes it takes so much work to find out what is allowed or actually going wrong with the submission, it takes finally connecting with the right person who actually knows or can do something about it. You have helpful and unhelpful people to deal with, then you have to find the helpful ones that actually know what they need to know and then find the answer to do something about it..And it all takes our time to sort it out, and it wasn’t by any mistake that we made.
It feels like the last 10 years there has been an escalation of issues that have to be solved. Maybe it’s because everything has become so much more costly, maybe it’s because the PBM’s have grown so much in the last few years, maybe it’s because there is a shortage of medical staff, and maybe it’s a combo of all of the above and then some. I guess my point is you have to be persistent.
I have just gone through it again twice in the last 6 months. Once in getting a copay bill on a chiro app which is supposed to be picked up by my secondary. Something that has been going on fine for years. My chiro told me I have a balance, no biggy but if it wasn’t sorted it could end up being costly after time. My secondary paid the first visit but I owed a copay on the second ??? I called my secondary and they said it wasn’t submitted to them, told the chiro to resubmit it, the chiro said they checked as they use a major service to submit it for them and it had been. So I called my secondary again and they said it wasn’t submitted to Medicare, That Medicare doesn’t cover it but I get visits through the secondary and I then owe a copay. But I know medicare does cover it, but that it wasn’t covered is coming from a supposedly helpful person that didn’t know what they were talking about. I was going to call again to talk to someone else a different day but when I called the chiro again they said someone else had had the same issue and Blue Shield told him they had a computer glitch that was now straightened out. All fixed thank goodness. I had visions of trying to straighten it out with the middleman because I had to do that with my back doctor last year and it took 4 months to straighten it out because the doctor switched who they used to bill in the middle of it. This year besides the chiro, I had the new pharmacy supplier and special approvals, and I am still messing with getting a change to my Humalog prescription amount sorted. I am not sure if that is the doctors office or the pharmacy supplier yet that is causing the issue.
I really appreciate this. I submitted the online form - unfortunately, when I spoke with Insulet over the phone they only offered me a copay assistance card that knocked $100.00 off. Respectively, it could be helpful - but my supplies would still be 491/mo for 2 boxes and I simply can’t afford that.
Apparently, even with PA approved, I’m outside of my pharmacy deductible and would still have to pay out $730.00 to find myself in the pocket to which… I don’t even know how much this garbage plan will even cover at that rate. We shall see, I guess. I am taking it one day at a time and my fight is not over.
I understand these matters can be frustrating. I’m glad to hear that you’re advocating for yourself and your bills to be handled through the proper channels. Unfortunately I went through all of mine, and it seems I may be losing the battle. Unless Insulet can pull some miracle for me, I’ll either be forced to attempt to meet my leftover OOP Pharmacy deductible, or I will be moving over to pens… which shouldn’t scare the 
out of me, but to be honest it does.
Tomorrow’s another day, I guess. I have 5 pods left.
I am so, so sorry to hear this. And so ^&*&^^% frustrated for you. This is nuts. My family will also likely move to a marketplace insurance policy next year and I am terrified for what it could hold.