I am hoping this forum will have some more up to date experience than I have been able to find on the internet at large. Most articles are from 2009-2012. I have 2 children who were diagnosed at 2 and 4 with diabetes. In 2012 we started them on the Omnipod through Anthem then the company changed insurances and went to Cigna, although not their preference and it was a headache, both insurances covered them. We are now switching to Kaiser. Is there any hope Kaiser will cover the Omnipod? We also started the Dexcom 5G and they said with continuity of care, Kaiser will cover that, I am really hoping the same will hold true for the Omnipod. Our insurance doesn’t start til next month so I am in limbo a little bit. Luckily we have plenty of supplies to get us through for a bit. I am just looking for some encouragement or hope that Kaiser (NorCal) will work with us.

i have not had a problem with insurance covering CGM or pumps for me, but I have heard others tell their stories. I believe that with a letter of medical necessity from your endo, you can launch a successful appeal if your insurance company dares not cover the pump…but I have not had to do so myself.

The CGM is arguable and some insurers are refusing to cover it.

Both are “Durable Medical Equipment” (DME) for me; covered by insurance but there’s a sometimes hefty deductible.

Best of luck!

Kaiser DOES NOT cover the omnipod, but will cover the CGM. You will have to fight for it, and your endo + the diabetes educator will likely talk you out of trying to fight for the omnipod. they will tell you all the things that are wrong with it and tell you that what they have is better. After telling the diabetes educator they are supposed to be on MY side, she gave me some tips on how I can fight for the omnipod. This is what Im going through now, and this is what they told me I need to do.

  1. Go to a diabetes education class where they teach you about the pump options available.
  2. you will have to appeal to the insurance board that the options they are suggesting for you are not good enough.
  3. The compliant will go to your Endos Boss for their review and then back to the insurance board- I believe at this point they will either grant or deny your request.

Unfortunately Kaiser only offers this diabetes class once a month - so Im only at step one. Its really frustrating, as I also want to be on the omnipod.

Try giving omnipod a call and see what they suggest.

Ill keep you posted on my process.

How did this battle end up going? I know its been a few year. I’m curious.
I have heard that Kaiser SoCal (and maybe NorCal) are in negotiations with Insulet for carrying the omnipod.