Does Medicare Cover Omnipod?

Does Medicare cover Omnipod? Over 14 million seniors in the United States are currently living with diabetes, and every year more than 1.5 million are newly diagnosed with this disease. For those who are insulin-dependent, having an insulin management system, or patch pump offers them many health and convenience advantages.

Medicare Benefits Solutions

Jun 25, 2021

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The Omnipod system, created by the Insulet Corporation, is a tubeless and wireless insulin patch pump that provides a continuous supply of insulin. You have complete control of the amount of insulin and the flow rate you get through the Personal Diabetes Manager (PDM). With the Omnipod system, you only have to fill a new pod with your insulin, place it on your body wherever you would normally inject your insulin and the canula automatically inserts itself there. You then press start on your programmed PDM, and the insulin flow begins. You can use the PDM to monitor your blood glucose levels and other important numbers to adjust your insulin accordingly.  

Without insurance coverage, the Omnipod insulin management system costs $800.00 for the PDM and $30.00 for each pod which can hold enough insulin for up to 72 hours. Even though the price for the PDM is a one-time cost, the pods are not inexpensive and can add up quite quickly. For Medicare recipients, having coverage for these costs is a valuable asset. Here’s a look at how your Medicare benefits may help cover the cost for the Omnipod.

Do Medicare recipients have coverage for wireless, insulin patch pumps like Omnipod?

If your healthcare provider has diagnosed you as insulin-dependent and has prescribed a wireless insulin management system like Omnipod, your Medicare benefits might cover the cost of the PDM and pods, plus at least two types of insulin. Your coverage and copayment costs depend on which Medicare prescription drug (Part D) or Medicare Advantage plan you are enrolled in and if they include Omnipod on the formulary.  

Medicare’s coverage for insulin and insulin delivery methods can be a bit confusing because different parts of Medicare cover different systems. As mentioned above, if the delivery system is wireless, the system, plus your insulin, falls under Medicare Part D coverage. However, if you use a delivery system that uses a tubed insulin pump, you get your coverage from Original Medicare Part B (medical insurance) if you are eligible. This equipment coverage falls under the Medicare Part B category of durable medical equipment (DME), and it includes insulin, pump, and supplies. To qualify for this coverage, you must get everything from a supplier of DME that accepts Medicare assignment. If your DME supplier does not supply insulin, there are many national pharmacies that are able to bill Medicare as DME suppliers. Your pharmacist can give you this information, or you can call a local CMS office and ask for details about local DME suppliers for insulin. 

If you have a Medicare Advantage (Part C) plan through a private insurance provider, they are required to provide at least the same coverage that you would get with Original Medicare benefits, both Parts A and B. Many Part C plans also include prescription drug coverage as part of the plan. If you do have this added coverage, you should check your plan’s formulary to see if Omnipod is included. If you aren’t sure, you can call your provider to get the details. 

What are some advantages of using a wireless insulin management system like Omnipod?

As insulin-dependent people know, giving yourself multiple injections every day, plus checking your blood glucose levels, and calculating your insulin requirements to fit your daily needs can be stressful and inconvenient. With a wireless system like Omnipod, Medicare recipients can find the following advantages helpful:

  • The pod is small in size so it isn’t uncomfortable and can’t be seen under your clothes
  • You can apply the pod practically anywhere on your body
  • You can skip your daily injections because you only have to change the insulin-containing pod every 72 hours
  • The canula inserts automatically and very quickly with just the press of a button on the PDM
  • It’s easy to program, can be done from a short distance, and through your clothing
  • There are no tubes that can tangle or snag
  • You don’t have to disconnect or reconnect tubing
  • You have better insulin regulation
  • You may have better blood glucose level control
  • It may reduce episodes of severe hypoglycemia

Your health care provider can help you decide if an insulin management system like Omnipod would work for you and let you know if your Medicare insurance covers the cost.

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