Confused on Omnipods.

[Rossat]

It's not DME. It's covered under Part D. Yet its on no carrier's formulary in my area PDP or MAPD. It's not in the EOC either.

It's not a drug that can be searched on Medicare.gov due to it being a device.

How can you help ensure a carrier covers Omnipods without calling each one?

 

[sshafran]

Been through hours and hours on it give me a minute.... I'll reply w/ info...

 

[sshafran]

Ok, here is the best link and process.

Run analysis like normal to pick Part D. Ignore omnipod for now.

Once that's done, check their list:

[EXTERNAL LINK] - Medicare | Insulin Pump Therapy | Omnipod

No computer will "figure it out" but they do list carriers and tier levels. Should be able to give an educated opinion of which plan works...

I do not know if they've updated their list for 2024.

 

[sshafran]

That fact that people (including doctors) refer to it as a pump was incredibly frustrating the 1st time I ran into it... I thought it was like the other "insulin pumps."

Nope.

 

[yorkriver1]

Thanks! Now for the Dexcom situation, DME pretty sure.

 

[ValeRosso]

Today I leaned what an omnipod is lol

 

[sshafran]

Thanks! Now for the Dexcom situation, DME pretty sure.

What's the question on Dexcom?

CGMs are DME

 

[yorkriver1]

Dexcom question: pretty sure some plans will cover that brand, and then only certain models and others won't, correct?

 

[kgmom219]

Reviving this one, because I've spent a bunch of time and effort digging in on it.

Omnipod is NOT DME. And its not a pump. Its considered "disposable" by CMS.

Omnipod is covered under Part D, subject to the deductible and the pods are typically tier 4. Assuming its Tier 4, $200 a month for the pods is a good guess.

Then they use a fact acting insulin, such as Humalog or Novolog, at $35/month.

Even better, the Omnipod information is not available on the Medicare Plan Finder and in most cases, at the carrier sites.

It is available at local pharmacies and also Advance Diabetes Supply. The issue with using ADS is that they are not set up that well on Part D, especially considering this one requires a Prior Auth.

 

[yorkriver1]

In the situation being faced by the client, it's pretty difficult, as the pods and Dexcom will add up to upwards of $300/month. Non liquid asset prevents Extra Help, and diabetic supplies doesn't mean items like Dexcom are a freebie on plans that say diabetic supplies are covered 100%.
Hopefully the client will be able to sell the asset they want to sell and have the ability to pay for the Omnipod system or get a good endocrinologist to help with alternatives.