I recognize that everyone’s mileage on UHC may vary depending on their employer or plan, but I wanted to jot down what I’ve learned recently in case it helps someone else.
Based on a discussion with the UHC representative and an Insulet representative (two separate calls) the OmniPod pods are, as of April 1, 2018 (for at least some UHC members), covered through the Durbale Medical Equipment (DME) coverage with United HealthCare.
Getting to the point where I figured this out was a rather involved process. First I was told by our pharmacy that had contracted for pharmacy delivery of the Pods in California with UHC (Advanced Diabetes Supply/ADS) that pods were a “plan benefit exclusion” for 2018. They suggested I call our insurer’s pharmacy coverage plan OptumRX, where they explained the process of calling UHC and getting a thirty day “transition of care” prescription if indeed Pods were no longer covered by UHC, which both the OptumRX rep and I assumed was the case based on UHC’s track record with coverage for diabetes medicines and supplies.
So I called UHC and they informed me that Pods were actually going to be covered under the DME portion of Diabetes Supplies! I couldn’t believe it, but it seems to be true. However I would need to contact our endocrinologist and get a Prior Authorization started - the phone number provided was 800-638-7388 for our provider to call directly. I emailed our endo to start the process straightaway.
I then called Insulet and heard that the new coverage goes into effect April 1, 2018. The rep kindly overnighted us spare Pods to tide us over until the coverage goes into effect. Apparently the pods are going to be covered under billing code VA9274 for DME with UHC. There’s still a copay, and now the Pods ship from Insulet directly, however I think this new approval for the OmniPod system and supplies might help people who’ve struggled with UHC diabetes supply coverage in the past.
The real take away for me with this process was learning about the covered-at-previous-rate 30 day supply of whatever priorly used medication/supply you need once you’ve been rejected by the healthcare company for coverage. Especially if your practitioner writes in a bit of overage in the RX to cover failure or unexpected use, one 30 day supply of an RX can last for some time. And for the record, the UHC representative NEVER MENTIONED THIS. I luckily had heard about “transition of coverage” from someone else and was able to ask about it. We have also been rejected from Afrezza this month, and I managed to get a 1 month supply despite rejection to cover our needs while I write an appeal. (Planning a thread about that if I can get it together…)