FUDiabetes

Omnipod as DME

I had a great run with Omnipod ordered directly from Insulet Corp. Insulet handled everything when I got started, orders showed up on time and hassle free and my co-pay was not too painful in the grand scheme of things. Now my insurer decides to switch everything up. Received a letter stating that “Insulet Corp is not currently in-network beginning on June 1, 2021”. Naturally the letter showed up about a week prior to June 1. I dread dealing with DME suppliers just to get boxes of pods…my guess at this point is my co-pay will double or triple and ordering will be a huge hassle.

I’ve tried with this insurer get pods covered under pharmacy benefit but have had no success. Their latest response was “Since Omni Pods are inserted into a medical device and administered through the medical device they fall under the medical device benefit.” LOL, it took them a few years to learn what a CGM is, now they need to go back to school about pods.

The question is: has anybody successfully cajoled their insurer to cover pods as pharmacy benefit rather than DME? My insurer says I should submit a grievance. Has anybody had success with this health insurer grievance process? My inclination is to call the pharmacy benefits dept. and educate them first before the grievance.

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@John58 , is your insurer UHC? Also, it may well take longer than you have to get the mega insurer to change. What would your cost be for cash through Insulet, and how does that compare financially to the pharmacy cost?

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It looks like the Costco CMPP carries them for cash\no insurance.

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No my insurer is local out of Oregon. Since I am in WA the in network thing gets tough. Thought I had it going great buying direct from Insulet but unfortunately they closed off that option.

I’ll look into the cash pay at pharmacy, might end up doing that. I just have to make it work for about 7 months until I join Medicare.

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My pharmacy benefit appears to cover the Dash pods but not the basic pods. I haven’t made the switch yet since I may try looping again since the G6 is more accurate generally (haha until day 8).

Under Medicare, pods are not considered DME and are actually covered under our supplement insurance (with a big co-pay).

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Still looking forward to all the confusing changes once I hit 65…I’ve had a good run with this insurance but all good things seem to eventually expire. I’m hoping to stay with Omnipod but no clue about the Parts B, D, Advantage etc. Thanks for the heads up about the Dash, I might be able to make that work with my insurer. At a minimum the Dash can be cash paid at Costco for a few months.

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Had a chat with a claims rep at my insurer and she explained starting June 1 they are now “partnering” with Cigna and my choice of in network DME suppliers will be the Cigna network. Hopefully is decent. Naturally and par for the course with insurers, I cannot access the info on Cigna.com, receiving the message “We weren’t able to verify your identity”. These bureaucrats will probably take a few months to get us all registered with our new “partners”.

A friend suggested “180Medical”…anybody had experience with them? I need somebody competent enough to process the prior auth paperwork etc. within a reasonable time frame.

EDIT: Got through to Insulet and my insurance pharmacy benefit rep: Insulet says the Dash is ONLY sold via pharmacy benefit, there is no DME supplier for Dash. My insurance online account information says Dash pods are “Not on foirmulary”. Called and the claims rep said it’s a piece of cake: get the prescrip and prior auth submitted, pick up 30 day supplies of Dash at retail pharmacy.

So the current plan is to change over to Dash, use up my old pods over the next few months and obtain Dash pods at the pharmacy. Time will tell if it all works out but fingers are crossed.

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I am exhausted just thinking about all those calls…

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Ha…not done yet. In about a week I’ll be calling to find out which party did not send a required fax to the other party.

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I get my pods through OptumRx as a pharmacy benefit. Under Medicare it has to be Pharmacy not DME. But I have Medicare and a supplemental and I pay $40 for a 3 month supply. I think my supplemental controls the charge to me, not sure, it’s hard to figure out. I would have preferred it under DME as I would have had a $0 copay. But I have been told it’s because the pods are disposable…but Dexcom sensors are disposable and they are DME lol, so it makes no sense! I think Insulet was just happy to get them covered under Medicare at all.

I have had no issues getting them through OptumRx. I do have to ask for them as they can’t be on auto refill for some reason. My insulin for them is auto refill, but not the pods.

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I think this perfectly sums up the insurance situation for diabetics in the US. Doesn’t have to make sense, it just is. And btw the system changes every 120 days to keep you on your toes.

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Medical policies made by bean counters…wait until AI takes over health insurance administration, that will surely improve things. Another thing that gets me about health insurance issues is this insistence on medical offices, insurers and suppliers faxing documents to each other without sending a copy or confirmation to the patient. There are fewer more old fashioned ways of bogging down communications but apparently HIPAA or some such nonsense compels them to keep at it.

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They do like their faxes! Couldn’t imagine a more antiquated time intensive way to share information. It is almost like they have never heard of encrypted messages, which could be used to cc the patient and still maintain HIPAA compliance, and save time+money since no one needs to prepare the fax and ensure it sent. But you know, reasons…I am on a roll today…wheeeee

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No, my insurance, Cigna, treats it as DME :frowning:

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What’s a fax? Didn’t those go the way of the dinosaurs in Y2K?

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You can still buy them apparently:

Pretty affordable, might put one in the office just in case I need to send a message to my physician.

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It’s possible you might get a faster response from your care team too…

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[Omnipod as DME]
Unfortunately I love my Omnipod Dash but my supplemental to Medicare considers it a Tier 6 which means I have to pay 40% of the cost. That equals $650.00 every 3 months. I can not afford it on our income. Meanwhile, in the process of seeing if Insulet will help out with the cost. I sent the info yesterday and waiting to hear back.

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Hopefully insulet does the right thing. That is not a huge cost to those of us with good jobs, but once on a fixed income these types of costs can bleed you dry, especially when they are additive, and no insulin dependent diabetic can survive on pump alone. Welcome to FUD @karen337.

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Welcome to FUD! Insulet has contacted me to say that the Dash is covered by my pharmacy benefit and would be much cheaper than my co-pay for Eros pods as DME. Might this be an option for you?

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