QUESTION: I am considering the Omnipod system to help control my Diabetes. Will Medicare cover it?

The Omnipod system is an insulin delivery system that allows you to not only monitor your blood sugar without fingersticks, but also administer insulin without needles. This system is along the lines of an Insulin Pump, but is disposable after 72 hours of use. This new insulin delivery system is covered under Medicare for very select individuals with insulin dependent diabetes. If you qualify for Omnipod coverage under your Medicare Part D benefit. The retail cost of the Omnipod system will impact how you move through your Part D coverage.

One of the ways we can determine coverage of medications is using the online tools such as Medicare.gov or individual insurance company’s websites. The Omnipod system is not available to research using the Medicare.gov website; therefore, we must go to the individual companies you are considering and research the coverage of this type of system. While doing the research for this article, we found the insurance companies websites didn’t list Omnipod as an alternative insulin delivery system. We did find the information about Omnipod coverage in the on-line formulary book accessed through the website or by calling the customer service number.

When my staff and I began the research for this question, we discovered that only 15 of the 28 Stand-Alone Prescription Drug plans cover the Omnipod system and 29 of the 36 Medicare Advantage Plans cover the Omnipod system. Many of the plans included Prior Authorization, and Quantity Limits as part of the rules of coverage. A Prior Authorization (PA) means your pharmacy will not be allowed to dispense medication with a (PA) designation without your doctor first informing your insurance company that the treatment prescribed is appropriate to the insurance company’s coverage standards. There were also Quantity Limits (QL) and three plans that would only cover this medication through the Mail Order Pharmacy benefit.

Our research indicates that most companies cover the Omnipod system, but most companies have some sort of limitation to that coverage through a PA, or QL rule. The Omnipod coverage is not as easy as that commercial on TV makes it sound.

The cost structure of the Omnipod will impact your medication costs as you work through the phases of coverage with Part D (deductible, initial coverage, coverage gap and catastrophic coverage). The Omnipod system is relatively expensive. We found that a 5 pack of Omnipods (each lasting 72 hours) costs between $250 and $400. That is 15 days’ worth of treatment, so you would need two refills or 10 Omnipods to go a full month. It is also important to remember that the Omnipods must be filled with Insulin prior to use, so the cost of insulin continues to be part of your budget.

Insulin has been a financial burden for diabetics for many years and this year 2021 has been the first year we have seen significant improvement in that situation. This year, 2021, the Senior Savings Model was introduced and has significantly reduced the cost of diabetes treatment for most seniors. The Senior Savings Model has prompted the Medicare Part D plans to reduce the cost of Insulin products they cover to seniors enrolled in the plans that offer this benefit. Although less than half of the available Part D plans offer this Senior Savings Model, the ones that do have significantly reduced the cost of Insulin for Medicare covered individuals enrolled in the plans. Some of those Senior Savings Model Part D plans cover the Omnipod system.

When considering this Omnipod system to control your diabetes, I would definitely encourage further research to be sure your current insurance will cover the Omnipod. I would also research your cost share for that coverage. The Omnipod may in fact do a great job controlling your diabetes, but there are other issues to consider as well. I hope we have illustrated some of those other issues.

Senior Life Matters is a community based program sponsored by Lutheran Jamestown. For questions, concerns or to reach Janell Sluga, GCMC, call us at 716-720-9797 or e-mail at SLM@lutheran-jamestown.org.