Pharmacy prices on dexcom and omnipod 5

Hi, new here to this. My wife and I have started new insurance and the pricing of the equipment went from being tolerable $80.00 a month to now close to $300.00 a month. My daughter was diagnosed almost 1 year ago. She has been doing well on the devices since weve had them almost 2 months synced. Any idea how to get these prices down. Omnipod states on there site that most insurance covers it to $40.00. Just looking for info.

Hi @Everruss101 . Have you met your co-pay? Maybe that’s the reason for the current pricing.

No but to see a price jump like that is insane.

hi @Everruss101 welcome to the forum. Insurance is weird. lower rate/higher deductible plans can be very much more expensive per year than higher cost/lower deductible plans if the things you need covered are covered better.

I have a plan and they switched my coverage to “coinsurance” which means no 80/20 split until I meet my deductible, and I have separate deductibles for pharmacy, doctors, and durable medical. Too bad. Then they have a cost schedule including if I want a non-preferred non formulary, I get to pay “the difference” up to my deductible. My first bills for the year can be in the thousands. And I have to tell you - I have really good insurance by today’s standards.

get the insurance company on the phone, better make a sandwich because this could be a long day. make them tell you EXACTLY how and why they billed you this way, and what deductibles, and what, if any, devices are covered differently. Sometimes a coding error can cost you hundreds or more.

Sometimes a letter of medical necessity puts a higher cost item back on the “percent spilt” (IE 80/20 , 90/10, etc.) before the deductible. Sometimes, and especially if you are getting run through the ringer, shopping a different plan could be in your best interest. I get my insurance at work and I sometimes work with my plan administrator to ask for certain coverage adjustments… if they say “yes” it could mean thousands in savings for me. it never hurts to ask. good luck!

that’s all I got I hope it helps.

I wonder if they are processing them through medical rather than pharmacy benefits, or vice versa?

Hi Russel,
I would suggest contacting the manufacturers of her devices. Often times, they have coupons to help bring the costs down. Also, they are usually very good at helping to get prior authorizations from insurance companies. Most times, insurance will not cover the equipment without one, but I have had at least one policy that would cover a very small amount without a PA, but covered at least half of my cost with one (until I met my deductible and then everything was covered in full).

That is another point that comes to mind, you will normally pay more for supplies/meds until you meet your deductible. Given that it is still the beginning of the year, either the change in cost could be because yoiur deductible is not met, or it could be the PA (as mentioned above) has expired. So, contact your insurance company and ask why the price has gone up. If it is the deductible, ask if there is anything you can do to bring your cost down - - you might be able to apply for a PA to have the supplies covered at a lower tier. The only way to find this out is to talk to your insurance company!

So, contact your insurance and the manufacturers to see what can be done to bring your cost down! That’s the best advice that I can give. Hope it helps!

Pam K.
T1D 58.5 years and counting!

Hi @Everruss101 and welcome. It sounds like you probably have commercial or private health insurance but tell us if you are on medicaid, medicare or something completely different. The couple of insurance companies I have dealt with since being on a CGM (Sharp, Blue Shield, Anthem/Blue Cross) all say I have to buy CGM’s from a Durable Medical Equipment (DME) supplier in order for them to be covered. Yeah, yeah, sensors are disposable, not durable. Medicare calls them DME so many insurance companies do the same.

Omnipod devices get covered differently, sometimes under the pharmacy benefit, sometimes under medical and DME, sometimes not at all. Call Omnipod, they pay for a company to look up your insurance, figure out the coverage and talk you you. Alternatively, look up Omnipod in your heath insurance’s pharmacy benefits formulary and Diabetes Supplies in the Explanation of Benefits. While you are in the formulary check the insulin your daughter uses. Some insurance companies price one brand less than another. Next check to see if they offer a discount for using a mail order pharmacy so instead of a monthly cost you pay (less) every 90 days.

Let us know if any of our suggestions are helping and if not, tell us why. We are here to help you.

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I’ve also found device reps and even my doctor’s business office to be helpful with navigating coverage issues.