Omnipod Insurance Coverage


(samiejo12) #1

Hello! My name is Sam and I have been a T1D since February 2008. I was immediately put on a Medtronic insulin pump 3 months after my diagnosis and was taken off in 2012 before I went off to college. I had been taking shots up until 2014 until I was admitted into the hospital for DKA (first time). After that I had been put back onto the Medtronic insulin pump until I was introduced to the Omnipod. Since starting the Omnipod in December 2015, my A1c has dropped from 10.2 to 6.6 (June 2016). Not only do I feel so much healthier but also “normal” especially with no tubes attached. I cannot put into words how much I love the Omnipod compared to the Minimed.

Here’s where it gets messy. I am still covered under my parents insurance (Aetna) and they refuse to cover the Omnipod supplies. Not only do I have the test results confirming I do not respond well to shots or the Minimed, but I also have referrals from both my physical doctor and my endocrinologist saying how much healthier I am now vs. the Minimed. I am beginning to lose hope of how I am able to keep my Omnipod without having to pay out of pocket for my supplies. I am a full time student working part time and cannot afford $300 for a month supply of pods. Has anyone had any success with the Omnipod vs. their insurance? If so, please let me know how you achieved such a triumphant accomplishment.

Note: I have already contacted Omnipod to see what they could do but so far no such luck.


(carmelor) #2

Insurances can be a complete pain in the a$$. What was the reason that they are not covering your supplies? How did you get on the Omnipod in the first place. Didn’t your insurance company have to approve it? Was there an appeal process? Have you talked to your local Omnipod rep? I know its 5 months away talk with your parents and see if there employer offers different insurance options and possibly switch insurance carriers. Can you get any insurance through your university that may cover your supplies?


(samiejo12) #3

The insurance isn’t covering it because it’s “disposable” and the insurance lists them specifically as uncovered. Omnipod was having a “no tubes attached” promotion so I paid $200 for the pdm and the first months supplies and then after that they bill your insurance. I’m not sure if we can appeal it because it’s already on the list that it won’t cover it. I looked at the university insurance and it’s through the same company so I think I would run into the same issues if I were to switch.


(carmelor) #4

So what you will need to do at this point since it says that it is listed as not covered. First check to see if there is a clause any where in there that states if something is medically necessary. You wouldn’t switch insurance carriers to your university since I’m sure your parents is better coverage. What you want to do is see if the plan will cover your pods and sign up for it, I’m sure it will be cheaper than 300 a month. Just because its the same company doesn’t mean anything. I’m sure Aetna covers the pods it all depends upon the policy. When your parents renew their insurance they should choose a new carrier or a new option that will cover your pods. Are you getting 72 to 80 hours out of your pod? The pod lasts for 3 days but gives you an 8 hour buffer. Also check out edgepark I don’t know if it’s any less expensive but you never know.


(brighter1085293) #5

Insurance coverage is a long-standing weakness of OmniPod, yet another reason exclusive arrangements like the one between United Healthcare and Medtronic should be overturned as anticompetitive/antitrust through litigation.

But, that doesn’t help you now…

A few tips that have worked for me:

  1. Use the insurer’s appeals process. Your doctor will be essential and you both will have to show WHY the Omnipod is better for your A1c control that the Minimed. This may get very technical. Are your A1c better because Omnipod’s PDM combines glucose meter, bolts calculator, and pump control? Was the Minimed unreliable and if so, how? (Poor occlusion detection? Clogged sets?)
  2. Try bypassing the insurer’s Durable Medical Equipment (DME) limitations by having a third part like Foundation Care or EdgePark submit the supplies as a pharmacy claim.
  3. Escalate to your state’s insurance commissioner with a formal complaint (https://eapps.naic.org/cis/fileComplaintMap.do)
  4. Write to your elected state and Congressional representatives describing your experience to oppose the merger between Aetna and Cigna

This whole area of insurance coverage is a significant FAIL for JDRF and American Diabetes Association, since neither organization has done any advocacy about insurance coverage for those with T1D.