I’m navigating the Medicare approval for insulin use in pumps….in particular the Omnipod. The language for Medicare coverage for insulin under Part B states it does not cover insulin (unless use of an insulin pump is medically necessary) and Part D pays for insulin that isn’t used with a “traditional” insulin pump. Is the Omnipod considered a “ traditional “ or does the tubeless feature make it non traditional?
In one of the previous questions, someone stated that Medicare is now asking for which pump is being used when billed.
If Omnipod is not considered a traditional insulin pump by Medicare and it is covered under Part D ( rather than Part B) like all the other pumps, should I expect that Medicare will not pay for insulin used in the Omnipod???
Just a note, the new legislation that says Medicare recipients will only pay $35 for insulin does not address the fact that the “billed cost” will be added to total prescription cost which will push us into the DONUT HOLE quickly!!
From the Omnipod web site,
" ### Omnipod® is covered under Medicare Part D.
https://www.omnipod.com › coverage › medicare
Omnipod® is covered under Medicare Part D. Insurance can be complicated - let us help! The information below includes tips and …"
As for insulin coverage, if you have coverage under Part D Medicare (which covers drugs including insulin), then I suspect the $35 maximum cost for insulin should also apply. You should double check with the specific provider of the Part D Medicare plan you have or plan to purchase to make sure this is correct.
In general when it comes to Medicare and insulin pumps Part B will only pay for insulin used in pumps bought and paid for using Part B. Specifically the Omnipod is not classified as “Durable Medical Equipment” (DME) which is part of the Part B infusion pump requirement therefore Part B will not cover insulin for the Omnipod.
Note that the $35 deductible for insulin applies to Part B as of July 1, 2023.
I found two resources that may help you navigate the medicare minefield.
JDRF has a nice illustrated guide to medicare coverage of pumps, CGMs and insulin
Medicare published a FAQ about the changes to insulin coverage with the dates when the changes become effective.
The following quotation comes directly from the Medicare website:
Your costs in Original Medicare
“The cost of a one-month supply of each Part D-covered insulin is capped at $35, and you don’t have to pay a deductible for insulin. This applies to everyone who takes insulin, even if you get Extra Help. If you get a 60- or 90-day supply of insulin, your costs can’t be more than $35 for each month’s supply of each covered insulin. For example, if you get a 60-day supply of a Part D-covered insulin, you’ll generally pay no more than $70.”
One additional comment with regard to Part D Medicare–something you should take note of: Not all Part D Medicare coverage plans cover all the different types of insulin. For example, I know of at least one Part D plan that will pay for novolog but will NOT pay for humalog.
@barb2 ,
The issue with Omnipod is it is not durable medical equipment (lasts 3 or more years) since it is a one & done use. One the other hand the PDA is used for more than 3 years.
Reading here and Facebook diabetes groups about Medicare, indicates POD coverage depends on how the prescriber writes the Rx for insulin. PODs are pumps and therefore should be covered, if the script is properly written.
I understand the logic that the Omnipod 5 is not covered by Medicare Part B because it only lasts for 3 days per POD. BUT….HOW did the Dexcom G 6 get covered under Part B? It sounds like the Dexcom G 7 that has a transmitter and sensor which lasts only 10 days will be covered under Medicare Part B. How does Medicare justify these confusing/ conflicting decisions?
Dexcom got classified as DME because the system as a whole includes a receiver which is durable.
The constitution doesn’t say the government has to make sense.
Medicare is complicated and everyone’s situation is a little different. What about your situation makes getting insulin covered by Part B better than having it covered by Part D?
All type 1s using an insulin pump get insulin under part b and it’s all kinds of pumps. It’s been Medicare policy for over a year now. Do not let a part D insurance company take your money. You will have to get your insulin usually at a Walgreens pharmacy but free is free. By the way CVS can not usually make it work. Your doctor will have to go through some paperwork submissions but after that you can get 3 months at a time free after your part B deductible.