FUDiabetes

Omnipod Dash system not covered by insurance?

I just received an email from Insulet, quoted verbatim (well, magic URL removed) at the end of this message. I’m not sure how to interpret this, apparently it means that Edgepark won’t ship the Omnipod Dash and, indeed, I just received a three month supply of UST400 (sp?) pods.

John Bowler

Hello John,

Thank you for your interest in the Omnipod DASH™ System. We regret to inform you that you do not have Pharmacy Coverage for the Omnipod DASH™ System at this time. However, we are committed to facilitating Omnipod DASH™ System access for all of our Podders™ and would like to initiate an insurance coverage appeal on your behalf at no cost or effort required from you.

While beginning the appeals process is by no means a guarantee of coverage, every appeal sends a powerful message to the insurer that choice matters. The Diabetes Community wants and needs access to the insulin therapy of their choosing – the Omnipod DASH™ System. While this is happening – rest assured your existing Pod orders will continue to be dispensed as they are currently fulfilled today.

If you would like to opt-in to the appeals process, [click here] to opt in and allow us to move forward on your behalf.

Thank you for lending your voice to help us secure access for all Podders™! We will be in touch as we learn more about the status of your appeal.

Sincerely,

The Omnipod® Team

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I feel your pain! I just transitioned to Medicare, which may not cover my Pods according to Insulet. I am not sure yet whether our secondary will cover my Pods either.

This has been going on for years, but I thought Insulet had obtained Part XYZZY coverage (whatever) for the pods. The issue was the supply code; Insulet’s competitors maintained that neither the PDM nor the pods were covered because their was no appropriate medicare supply code. One has now been added. If they have a code and you can persuade CMS (Medicare) to pay for a pump (any pump) I believe you will be covered. CMS apparently doesn’t believe us old fogies need pumps but if you had one before they don’t (can’t?) change your treatment.

The Dash issue seems to be a PBM issue; my insurance uses EdgePark, if EdgePark won’t supply a product (because the cost is not high enough) my insurance won’t cover it. Insulet would not supply me directly last time I asked; I could pay Insulet myself and they charge far less than EdgePark.

I looks like Insulet are gearing up for a PBM war, accumulating patients who have been refused coverage for their product and preparing to fire a first salvo at the insurance companies. The PBM’s are technically their contractors. Still, I’m interested in who has received this email and what the interpretations are.

John Bowler

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Thanks, John, that info helps a lot. We unlimited geezers demand our pumps!!

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For what it’s worth, the Dash pods cost a good bit more than than the PDM pods.

If you are doing a cash buy directly from Insulet without insurance, the cost of the new pods is $477 for a box of ten pods. The old ones are $299 for a box of ten.

There isn’t a lot of new functionality withe the new ones, so why would insurance want to cover that. Not defending their decision, just saying it costs 59% more and doesn’t really do much more for you.

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There isn’t a lot of new functionality withe the new ones, so why would insurance want to cover that. Not defending their decision, just saying it costs 59% more and doesn’t really do much more for you.

Integration with Tidepool is a really big deal for me. I have a RileyLink, but I need to either have an iPhone (which I find unusable due to the UI) to use that easily. This is actually my fallback, I’m sure I could manage to learn iPhone but I just spent several minutes swearing at Siri on a friend’s iPhone trying to get back to the home screen; it wouldn’t go away yet it clearly understood the meaning of an instruction to FOAD.

Everyone puts the price up with the new stuff; it’s a sawtooth, the price drops slowly on the old stuff then jumps to about the old level on the new stuff. We have medical cost hyperinflation, so the Insulet price change doesn’t seem unreasonable; they charged $25/pod years ago, when I last paid OOP.

John Bowler

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If your intention is to DIY Loop, you will want the older 433mhz pods until Insulet releases the next gen with full loop capability sometime in 2020?

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If your intention is to DIY Loop, you will want the older 433mhz pods until Insulet releases the next gen with full loop capability sometime in 2020?

Ah, ok; so it would be a change to the pod? I’ve been trying to work out what the options are. Insulet had stated they were going to swap all current customers to the new pods this year but it’s hard to find out what is going on. Their web site now seems to be offering both the old and the new systems.

Of course the other thing about the new system is that the PDM is “free”; I assume this is part of the reason why the pod price has increased (because it includes the cost of the PDM, though that would make the PDM $8,544). IRC this is part of the end run round the billing code blocks with Medicare; only one code is required.

One personal advantage I see in the new system is the integration with the Contour Next One system; I much prefer it over Abbott, the test strips for the old PDM are pretty much unavailable and very difficult to get through my insurance and, anyway, I use the Contour with my G6. (I do, however, buy the strips on line because they are so cheap given the amount I use now and the cost is so low.)

John Bowler

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@jbowler Below is the article from Loop post announcement on how to make the 433 mhz pods work with Loop if you are interested.

Omnipod LoopDocs

If you want to wait and use the Tidepool algorithm with the new Dash pods, you will not need a Rileylink to loop - but you will have to wait. For a while since the FDA needs the application fees prior to approval.

Thanks for the link; I’m getting RileyLink updates (I got the release announcement a week last monday) and will probably go with that. I can get a refurb iPhone6S for the price of the RileyLink, but I would have to pay the $99/year developer account cost too.

There is a lot of activity here. A few weeks back I found an Android solution that looks a lot cheaper; Android APS with an RFM69HCW on a Pi Zero (about $30). There is also this guy:

He has a rig that goes Android phone->RPi->RileyLink->Omnipod, which seems a curiously complex approach.

Perhaps there will be a long term market for the Insulet UST400 pods. It would be relatively easy to build an appropriate radio module into a cellphone, indeed maybe there are some out there already; my phone has FRS support which overlaps the Omnipod frequency band and is probably a lot more powerful (though not legal to use in the US, most likely for that reason.)

John Bowler

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Yes, you still need a RileyLink 433Mhz, plus Raspberry Pi, but it does provide the basics for integration with AndroidAPS. You can use xDrip+ and your Android phone w/ this setup. I’m waiting for the RileyLink back order still but plan to configure this once it arrives.

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@Trying: I have all the components on hand - I’ve got a couple of PiZ’s lying around and one of them is the PiZW (required for this - omnipy needs the bluetooth). I might even be able to use my phone as the power source; it has a 10,000mAh battery and a USB-C port.

Setup looks pretty simple, the main issue seems to be getting a robust case for the PiZW+RileyLink. I would guess that the RileyLink battery isn’t required if it is permanently powered from the RPi 5V supply, or maybe the LiPo socket could be supplied from the 3.3V output.

Worth a try I think, I’ve got spare pods in the likely event of losing a couple trying to get it all set up.

John Bowler

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Great, you are all set. I’ll be interested in seeing how it goes. I have the PiZW but who knows how long the wait is for the new RileyLink! Good luck in setting it all up!!! And then testing it out!!! Hope it gives great results!

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Received same email. Very confused as well on how to proceed. They asked me to appeal. Dont see harm in that but just heard about looping which only works with current pods. Do I fight or do I stay? Also with dash u need separate testing meter. Have you tried using the medical coverage from insurance? Ive been doing that for dexcom.

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I use DME benefit from my insurance but they only cover half!!! is there anything i can do about this?!?!?

Welcome charity2301!

Check with your insurance company whether they cover the pod as a pharmacy benefit. So far as I can tell all the US insurers are swapping to the pharmacy benefit, not just for the Dash pods but also for the previous, UST400 pods. (A couple of months ago I received two five packs of UST400 pods from Walgreens and only realized when I pulled the backing off the package of a pod and saw the canula cover had reverted from blue to clear!)

Now the pharmacy benefit may pay higher or lower than the DME benefit; you find that out from your plan details. Remember it is open enrollment period the time when you consider changing your insurance policy; do this every year.

When I choose my plan I only consider plans that pay 0% of anything, because only those plans allow me to pay my medical cost from pre-tax income. Doing this reduces my costs by the tax I would otherwise pay on $6000. As a result I don’t care much about DME vs prescription but I do hate Edgepark and Walgreens is OK; for example they admitted the wrong-pod mistake instantly and it only took three phone calls after that to get the replacement Dash pods.

Your plan controls what you do next. Even if you are on an employer plan you need to look at the potential benefit of swapping to an ACA plan but bear in mind that employer plans seem to have been in a constant flux and may change substantially this year.

I assume you are below the out-of-pocket maximum[1] (OOPMax) though, because your plan is paying something. So you must have some kind of plan which is at least ‘silver’; the deductible[2] and the OOPMax are not the same as they are in the bronze plan that I buy.

Consequently you do need to consider all the numbers. This is the standard insurance thing; you need to calculate the total for your covered medical expenses over the year and see where this puts you in the range between the plan deductible and the plan OOPMax.

I the actual cost of a one month supply of pods is somewhere between $300 and $350[3]. The price Walgreens tells me it charges moda for a one month supply of Dash pods is $617.99. The price I was paying Edgepark earlier this year for one month of UST400 (not Dash) pods was $531.15; Edgepark billed $1312.66, but $531.15 is the “negotiated” price that I paid, moda paid nothing.

So for me the DME and pharmacy benefit costs are the same; Dash pods cost more than UST400 because they include the cost of the PDM, about $1000 per year. It doesn’t matter how I get my supply.

It’s not directly relevant to the question you asked, but notice that the price I pay is about twice the Insulet cost. This seems to be true for everything I get through moda; the insurance company doubles the price so that I pay the full cost plus a top-up for the insurance premium. My OOPMax is $6000 so I actually pay an extra $3000 to moda over the year. If you get a “silver” plan you pay the extra up front, so silver and higher plans typically don’t make any sense; you pay the same, or more, if you hit the OOPMax and you pay a lot more if you don’t.

[1] Out-of-pocket maximum, or OOPMax; the total amount you pay in a year before the insurance triggers and pays everything for the remainder of the year. OOPMax is basically the amount you are responsible for; it is the same as the deductible on car insurance except that you only pay the OOPMax once a year.

[2] Deductible; not the same as the deductible on car insurance. When you have paid this amount the insurance company starts reducing the price you pay. The OOPMax still controls the total you pay, the deductible means that you reach OOPMax slower so at the end of the year you may find you have met the deductible but the OOPMax. If you meet both you need a plan with a lower deductible; it will cost less, if you don’t you need to do the math.

[3] The actual cost is what the manufacturer would retail price the product at if sold directly; it’s the same as the price paid in other countries either by the government or the consumer. It’s a while since I bought pods directly from Insulet so the number I gave is pretty much a guess. Perhaps someone who is currently supplied directly could fill in the prices? See this link to a diatribe article from 2013 and search for “price”.

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I have Anthem EPO which has a $0 deductible, and pays 50% coinsurance. I used to have an HMO that said the same thing as summary of benefits, but they actually worked something out and were able to fully cover the pods and CGM, unfortunately i no longer work for that company which offered that insurance and my husbands insurance is Anthem BCBS and this is what they cover. i am trying to appeal their categorization as DME and i hope they can cover the supplies at full cost, but who knows if it will work. i even have a letter from my Endocrinologist saying i need these supplies to be covered, etc. But, not sure if others have BCBS and were able to fight it out and actually get coverage. i also found this advocacy website that sends emails to all the insurance companies asking for coverage and giving reasons why etc. Let me know if any other Anthem BCBS people out there have gotten coverage.

How much do you pay for 10 UST400 or Dash pods? I.e. for a month supply.

i never tried to get one month supply. i have only been offered 3 month supply.

How much did you pay for that? (I.e. the 3 month supply?)