We recently ordered the free month trial of the Omnipod 5 and the pharmacy told us that our copay for the pods was going to be well over $1k for 90 days of pod supplies. This seems unusually high given that our insurance is pretty good and our copays for insulin and Dexcom G6 sensors and transmitters have been <$100/90 days for many years now. Is there some reason they might be overcharging for the Omnipod 5? Or is there somewhere else I should check with insurance to make sure that this pharmacy is coding/billing correctly?
The insurance company probably hasn’t added it to their formulary yet. If that’s the case they either aren’t covering it or at a nominal amount. I would call your insurance company. Omnipods are covered under Pharmacy for Medicare, but they were covered under DME by the same company before I went on Medicare. But the different plans, sometimes governed by the company you work for, coverage can vary a lot. Omnipod 5 is really new so not everyone has picked it up yet.
Thank- I’ll definitely call to check up on it. I’m on Blue Cross Blue Shield Federal Employee Plan if that helps anyone else. They’re already covering the G7 better than the G6 (same copay, but only sensor one needed) and that’s newer than the Omnipod 5 so I wouldn’t think it’s a formulary issue, but I will definitely check with them before ordering. Also, I know that the G7 is not compatible with the Omnipod 5 yet- the G7 is for me and the Omnipod is for my daughter who is still on the G6.
I had to go through quite a runaround to get coverage for mine at all, ultimately there was someone at my employer benefit office who had the authority to prior auth any “med” for any individual, and they did so for the om5…. It was a fairly dysfunctional process with a lot of back and forth….
I called Tandem and they told me where to get the best price with my insurance. Maybe they could help in your case too.
Sounds like you have a top shelf plan. Most likely someone checked a wrong box somewhere, and in my experience, no one in managed care actually looks at, no less thinks about, what they’re doing. I had a year-long scuffle with my insurer because they pre-approved and covered a colonoscopy (I know, different thread), but then they subsequently attempted to deny coverage for the necessary anesthesia, claiming it was a separate procedure. Genius.
We’ve had a lot of problems with anesthesiologists not because they try to code it as a different procedure, but because the provider was out of network. My last colonoscopy and at least one of my wife’s C-sections had this issue. Main provider is in-network but the anesthesiologist isn’t. I don’t know why it works this way, but our surgical bills get dinged for that as well. Usually some letters to our insurance explaining the situation gets us some mercy on the bill.
Unreal! As if you are going to think to ask the anesthesiologist - who you’ve never even met before and was assigned to you by your in network whatever - what insurance plans he takes while you’re already sitting there naked on the table, ready for your procedure…