Starting twiist pump on Medicare

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In order to get the twiist pump on Medicare, first I asked my endo to complete the Formulary Exception form for my Part D Medicare insurance (Healthspring, formerly Cigna). That’s about a five page form. I filled in the parts that I could to help the process along and the endo did her parts. The endo’s office faxed the form to Express Scripts and I received a phone call 5 hours later saying it was approved! I called Sequel to order the pump and schedule the training. They told me to expect a call from a local sales rep, the pump will ship from Byram, Sequel will contact my endo to complete the order with Byram.

Since I’ve been using Omnipods on this Part D plan I will hit the Out of Pocket annual max ($2100 for 2026 calendar year?) with either Omnipod or twiist, so it looks like a zero net cost change of pumps. And not locked in I hope and able to go back to Omnipod if twiist doesn’t work out and/or if Insulet ever gets around to upgrading the pods and software (as announced in Dec. ‘25).

I have been using Dexcom CGMs for years but will need to switch because twiist pump only communicates with Eversense 365 and Libre 3 plus (15 day). My endo gave me two samples of the Libre 3 plus so I started wearing one earlier this week to test it against Dexcom G7 and fingersticks. After these two sample sensors I’ll decide between the two CGMs and get started on the twiist. (I’ve read all the bad reviews of Libre but decided to see for myself if it will be OK. If not, I’ll go to the Eversense 365 but no idea when I can schedule a sensor insertion. The nearest MD certified to insert is a 3 hour drive from me.)

As far as I can tell, both Eversense 365 and Libre 3 plus CGMs will be 100% covered as DME by Part B Medicare and my supplemental insurance.

I’m really looking forward to using the twiist, especially an actual infusion set (vs. the little doinker angled cannula on the pods) and a much better Loop software setup than the frustrating Omnipod 5. Have never used a tubed pump but hoping it’s an easy transition. Wish me luck!

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Thanks for the update John and please let us know how it goes.

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@John58, Congrats on your success of the Part D appeal! I’m always negative about appeals like that but you never know unless you try. Great to read of your doctor supporting you with the appeal.

I’m thinking you’ll like the twiist Loop software. I’m really surprised that Eversense has no qualified MDs to insert the sensor in your area. I found out there is a doctor in my neighborhood who is just getting started placing the 365 sensor. I’ll give her several months to get more experience and use up some of my G6 shelf stock.

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I’m only a few days into my side by side comparison of 15 day Libre 3 plus to 10 day Dexcom 7 and ready to give up on the Libre. While user friendly and easy to start and use, Libre consistently reads 10-20% low, compared to fingersticks and G7. There is no option to calibrate. Meanwhile, G7 does much better and has not needed a calibration.

I’ve reached out again to Eversense asking the local sales rep to look into availability of Dr. to insert the sensor now and in immediate future. Not sure I am willing to start the new twiist pump using BG data from Libre, but also don’t want to wait months for Eversense availability. If necessary to get started soonish I will make the 3 hr. drive for the sensor insertion, hoping a Dr. closer to Seattle gets certified within a year to take care of the removal.

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Me too; I don’t believe them. Not once did I see a detailed log or analysis of CGM errors. Sometimes I got the impression that the person writing the review was not familiar with the inaccuracies of other CGMs, well, the inaccuracies of the Dexcom; I still don’t have any data for Eversense.

I’m using Dash/AAPS/G7 and probably won’t change soon since my endo was down on the Libre; May 6 I will ask about EverSense unless I forget (endo keeps talking about Alzheimer’s; weird, I remember he keeps repeating stuff).

The 2026 OOPMax is $2,100, but with Dash and insulin on a Part D costing $110/month age 65 I come in under the max (so far). It’s a close call with a Part D with a lower premium and, of course, I’m gambling; the safe bet is always to go for the cheapest Part D premium when you know you are close to the OOPMax.

That said the story with the twiist isn’t clear; I’m using UNH and I suspect that since they support twiist in many other prescription benefits they may be a formulary exception (I’ve not checked yet). So far as I can tell Part D providers determine coverage themselves and will cover things that are not covered by Medicare itself.

I may have more info after May 6; bug me.

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Dexcom seems to read consistently high; my AAPS calculated HbA1c is way higher than my lab measured HbA1c.

My impression with earlier Insulet/Abbott (the Eros and maybe before) is that Abbott also read high.

My impression with AAPS is that it certainly runs high, i.e. higher than the target. I should add that my target is low; 100mg/dL, and it would not be unreasonable for AAPS to dunce me for that. I haven’t checked the code; this is black box.

Now if only we could get some real cinema; some diabetic Dude with the Godawful, the Free and the Ever all operating continuously over many months just to compare the numbers. Of course they couldn’t afford the lawyers to actually measure said Dudes BG accurately.

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The Think Like a Pancreas podcast did some testing and found that the Dexcom was more accurate at low BG levels, but the Freestyle was more accurate at high BG levels. Which is one of my main reasons for not considering using the Freestyle, in addition to no calibration. With a target like 90-100, I really need the accuracy at the lower levels! I’ll be interested to hear if Eversense has any accuracy patterns like this.

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Surprisingly, so far the Libre has been reading wildly low (more than 20% low) on BG above 150 and reasonably close to fingerstick at 70-150. Dexcom has stayed within 10% throughout…I suspect that my second Libre sensor will perform differently. Time will tell, they go for 15 days

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I’m having trouble getting this to work right. I tried to quote @jbowler on HbA1c and GMI discrepancies. For some reason my post also goes in a quote block and will not post. But I refuse to be thwarted​:winking_face_with_tongue:

Mine as well but they are really apples and oranges. What Dexcom uses is basically a mathematical average of the recorded BG.

HbA1c on the other hand is measuring glycosated hemoglobin in red blood cells.

While the 2 numbers can be close- that seems to be in 0 19% of cases with maybe 51% 0.3% and the rest at 0.5% differences.

From what I’ve read there is no definitive reasons for the discrepancies.

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I was using AAPS for the HbA1c. The number should be randomly lower or higher but my lab result has consistently, over several years now, been lower. In fact I have never seen the estimate be lower than the lab result. Relion HbA1c test strips have shown the same thing and have, in fact, been closer to the lab test (i.e. within 0.2).

I checked my Abbott Precision Xtra meter against my Contour USB this morning; the Contour USB came in with 112mg/dL and at the same time the Precision Xtra came in with 105mg/dL. This is pretty consistent with other checks I’ve made; the Abbott result was 94% (-6%) of the Contour (was Bayer, now Ascensia) and vice versa the Contour result was 107% (+7%) of the Abbott.

I saw this consistently with the FreeStyle test strips on the old Insulet Eros pods and other people reported the same. Abbott was criticized widely at that point because the assumed-to-be too-low result caused lower corrections and, therefore, higher HbA1c. (At least IRC; it’s easy to get mixed up because a high BG result causes a low HbA1c…)

Reporting high causes over-correction which, while it is dangerous, also makes people happy; endos see a lower HbA1c and praise their patients.

The Dexcom kit is calibrated using a 2-variable calibration which is I suspect just linear-regression. It’s a functional approach because it implicitly deals with random errors. I would be interested, surprised even, if Abbott did anything different with the Libre.

The problem is that if the slope is increased the offset can be adjusted so that the readings are still correct at a given set point, e.g. 100mg/dL, or 80mg/dL, yet this results in a more “aggressive” response to both high and low BGs. The final average result depends on the patient’s BG distribution around the set point.

My feeling is that I want accurate results; I don’t want the iCGM participating in the aggressiveness of the iController. However there is very obvious marketing pressure to produce better results by tweaking the iCGM to make the iController more aggressive, after all it is typically the patient who gets victim blamed for the low BG from an overcorrection.

With the iCGM/iController/acePump separation this gets much worse; now the iCGM manufacturer has shed all the responsibility for the iController failures, even though if the iCGM is aggressive it is simply lying to the iController.

The HbA1c differences I was seeing were something like 5.7 actual, 6.1 eAG to 6.3 actual vs 6.7 eAG. So that’s 6-7% over on the BG readings (and hence the HbA1c). This is consistent with the actual measured difference above but, of course, that’s on the test strips not either iCGM.

iCGMs can be +/-20% of actual, so in the limit one iCGM can read 50% higher BG values than another and still be “fine”! Clearly I’m not talking about that; both Dexcom and Abbott are well within range, though maybe someone could test both when their BG is around 200mg/dL; differences should be largest (in % terms as well as absolute) at higher BG. Note that this is because the set-point is greater than 0mg/dL, I think I got that right; the % increases above the set point and decreases below :wink:

What particularly worries me is that iControllers might be tuned to Dexcom because of its prior US monopoly; iControllers might be implicitly assuming an aggressive iCGM, so a correct iCGM would, in fact, be interpreted as “wrong”!

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The twiist starter kit arrived today and I’ve been contacted a few times by a sales rep supervisor type followed by a local rep to set up training. I’m going to wait about 3 weeks to start on the pump for various reasons but especially to gain a bit more confidence in the Libre 3 plus. (I gave up on the first sensor which was consistently low and false alarmed every night. The second sensor seems to have more tolerable accuracy.)

The contrast is noticeable between the proactive communications from Sequel sales reps and the spotty response from Eversense sales reps. At this point I’m leaning toward starting the twiist using the Libre and see how things go. I don’t have time the to bird dog Eversense to try to buy their product. Especially since they don’t have a Dr certified to insert the sensor anywhere close to Seattle.

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I don’t know if this is accurate but GOOGLE AI says these Seattle surgeons are qualified inserters:

Dr. Andrew Ting, MD (General Surgery): Located at Swedish Surgical Specialists - First Hill (801 Broadway, Seattle), Dr. Ting specializes in general surgery

Ryan J. Martinez, MD (General Surgery): Located at Swedish Surgical Specialists - First Hill (1221 Madison Street, Seattle)

Oliver C. Bellevue, MD (General Surgery): Located at Swedish Surgical Specialists - Edmonds

Concierge Bariatrics (Dr. Griffin): Specifically lists performing in-office Eversense insertions

EvergreenHealth: Michael Eickerman, MD (General Surgeon)

Evidently Eversense had a “Inserter Locate Tool” that allowed putting in a Zip code. None of the links work. They just go to an Eversense page that does not have the tool.

I guess I had too much time on my hands this morning and was avoiding the householdy chores that need doing.

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Thanks for that info! Most of them are in network with my endo so maybe will take me on as a referral from her. I’ll see if I can get through to this local Eversense rep and check out these potentials.

The part of me who always keeps his options open says locking myself in to a sensor for a year is not my typical style. I’m leaning toward the Libre because it will be easy to switch back to Dexcom + pods if the tubed pump ain’t my thing.

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@John58 I wasn’t trying to steer you to Eversense. It is just your remark about no inserters in the Seattle area sent me on a quest. Probably tilting at windmills.

I don’t understand why Senseonics did away with the provider finder tool. It makes no sense sonic or otherwise to me. Perhaps they want us to jump through all their hoops to convince us how great it is.

As I said before, I am not interested in anymore cutting and extracting on my body.

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@CarlosLuis No prob, I get that! I got a call back from the sales rep…those Drs you found are all in network for various private insurance but don’t/won’t do the insertion for Medicare. He thinks they will have somebody working on the Medicare pay scale and in my area by the end of the year.

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You’ve got the twiist but you haven’t been sold the sobriety; so Sequel give you support and EverSence gives you spam. Don’t judge them for that; it’s the difference between being face up in a fight and face down.

EverSense are selling and it’s not one of those “buy now for a 30% discount” deals, well, maybe it is. After you have eliminated the Libre3+ that deal will still be on the table and all you will have spent is a bad deal. A bad deal that might alternatively be a very good deal!

I’m 100% with you on your reasoning, but I’m very conservative. I don’t change two things at once (iCGM and acePump) if I can avoid it.

Simplify, simplify, simplyfy. It’s idiotic but it works.

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I’ve been using a second free sample Libre 3 plus sensor for 4 days now and it’s no closer to adequate than the first one…with no option available to calibrate it. I am going to bite the bullet and find a way to get the Eversense 365.

The apps tell me my average BG over the past 7 days was 118 according to Libre or 147 according to Dexcom G7. Here’s a screenshot of this morning’s comparison, while fingerstick had me at 170.(Exactly double the BG reported by Libre…)

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Too bad the Libre 3 didn’t perform better than you expected. Now you know that, for you, it cannot be trusted to steer an AID system.

For myself, with due diligence, I’m thinking I’ll at least give the Dexcom G7 10-day a try before I make a final commitment to the ES-365.

Thanks for the report!

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I hope it works well for you. I think Dexcom has corrected the quality problems many users (including me) experienced in 2025. My G7 10 day sensors have been flawless for the last few months.

The other reason I’ve been hesitant to start the Eversense 365 is the year-long commitment to that sensor. Sequel is staying quiet about adding Dexcom to their list of CGMs to use with twiist but that coordination with Dexcom is hopefully a high priority for them.

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That sounds like a solid plan, you have clearly thought it through. The switch to tubing can feel strange at first, but a lot of people adjust quicker than expected. Hope it works out well for you.

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