Medicare and Omnipod

I am on Omnipod5 and will be eligible for Medicare next year. I’m happy with Omnipod but from what I’ve read about processing of Medicare claims and delays getting supplies, I’m thinking about switching back to a tubed pump - although they recommend changing every three days, using those I could extend wear time if necessary. Omnipod5 ends after 3 days, period - no extensions.
I may be worrying too much, but for people on Medicare who use Omnipod,

  1. How was the process when you first switched over?
  2. What has your experience been with getting your supplies as far as processing times?
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Dear Doris
I too am using an Omnipod pump and I turn 65 this coming August. I have been trying to figure out which part D plans cover Omnipod and am finding it extremely confusing. I too am looking for more information and will try to share anything I learn. I would also love to hear how hard it is for tandem users to get covered under part D as the might be much less expensive.

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Insulet Omnipod was my insulin pump for over 10 years and fortunately covered by insurance through my employer. When I aged into Medicare two years ago, I faced questions similar to yours about the program’s coverage level for Omnipod. The following highlights what I learned and experienced and hopefully will help you.
For starters, Original Medicare Part B covers tubed but not tubeless insulin delivery systems like Omnipod. Part B also covers insulin if it’s delivered with a tubed system. So, to continue Omnipod while insured under only Original Medicare, you basically buy Omnipods and insulin out of pocket with current regulations. For some level of Omnipod coverage, you can enroll in a Medicare-approved Part D Prescription Drug Plan. You might intend to go that route for your prescriptions anyway. By the way, Part D Plans are private companies that cover some Prescription Drugs. These Plans are separate from Original Medicare Part A + B and each Provider’s Plans and Formulary coverage varies a lot.
Even though Omnipod is a medical device for FDA purposes, these tubeless pumps ironically fall under the Plan D Prescription Drug umbrella and not Part B coverage. That’s why Omnipod’s not covered by Part B like tubed insulin pumps. One big challenge I found is that some, but certainly not all, Part D Plans include Omnipod in their covered Formulary. Part D Plans also seem to cover some but not all insulins. On top of that, those Formulary restrictions add another challenge to select an insurer that works best for you: Find a Part D Plan with a Formulary that covers your routine prescriptions, your Omnipod 5, and your insulin. It’s not easy yet it is do-able.
For me, getting Omnipods is not the problem. The MD submitted Rx and supplies are released like always. The most difficult annual enrollment issue is to determine what Part D Plans provide coverage of my Rxs, my insulin, and Omnipod and at what percents. Another burden is Medicare site’s Part D Plan selection tool historically fails to include a way to search for Plan Formularies that cover Omnipod device. Medicare’s Search Tool currently includes drugs. Yet Omnipod is unique as a device that’s covered by Part D. So Subscribers like us need to find and check Insurance Companies Plan D Formularies on their own.
Medicare Advantage Plans are options you might want to explore. Their features didn’t align with my overall medical care needs so I didn’t investigate them thoroughly. I don’t know if or how reliably they cover Omnipod and insulin.
I remain hopeful that Medicare will close the Plan D search gap to include versions of Omnipod which will make the search and Part D Plan selection vastly easier for Subscribers. Then again, if Part B covered Omnipod like multitude of medical devices, it would be a real asset for T1D people when it comes to better care, costs, and the time-consuming choice to find a Plan D. Okay, I’m venting. Yet hopeful for a productive policy change.:astonished:
Rest assured, your early start to explore Medicare plans is well worth it. With T1D, your thorough selection process will make you feel more confident that you chose a good approach to best fit what you need. Please keep the conversation going since we’re in this together. Good luck!:blush:

On the outside chance you did not see this, here’s a reference from Insulet Omnipod regarding Medicare coverage options:
[Medicare | Insulin Pump Therapy | Omnipod].
I look forward to learning what each of you finds and how things work out for you.

what part D insurance plan did you choose? How is the coverage for your omnipod?

I am thinking seriously about talking with my doctor at my next visit about switching to the Mobi - or the X2 if Mobi isn’t covered.
For those who use the Mobi - I know changing sites every 3 days is recommended with most pumps, but is it required? I feel better knowing I can extend my wear time if I have issues getting my supplies.

@wadawabbit required? no. Mobi is not like a pod that drops dead on a timer. It keeps pumping until it runs out of insulin, whenever that happens. Just like medtronic or tslim. Mobi has a really small reservoir (cartridge) ~170 units (max)

Thank you @joe - for confirming what I thought. It sounds like I can get 4 days out of it if need be. Much appreciated!

SilverScripts Plus. Coverage for Omnipod 5 and other Rxs may vary based on your location.

Great to know. Thank you!

I am on medicare and I’ve been on Omni Pod for several years now. I get my omni pod supplies from CVS with no problem .
(a 3 mo supply)
I now get my dexcom 6 from Reliable Diabetes Care (New England based company) also a 3 month supply
The only issue I had with going on to medicare is that they required a C-Peptide blood test to prove I had diabetes (dah) and nobody bothered to explain why my supplies were held up until I had the blood test.

Apparently this hold true at age 65 no matter how you take your insulin.

If you are happy with Omni Pod and not having to deal with tubing, explore the the change over with your supplier before you turn 65


Thank you much @Anne98!