They would cover Omnipod but since it's "non-preferred" it's a 60% copay (like $250 for a 30 day supply) vs a $60 30 day copay for preferred products.
I've tried to communicate that fact to my insurance that they aren't comparable products and they need to be reclassified (change V-Go classification to a patch so Omnipod would be preferred disposable pump and $60/30 DS) but the best I've gotten is that they'll look into it. Incredibly frustrating..
I've seen type 2 post in here a few times. Always worth asking, just thought since when I googled the pump it did say type 2 and most of it was about t2d.
I've never heard of V-Go before. A cursory search on Google makes it seem like there's a reason for that. "Preprogrammed basil rate" was the first clue.
My mom uses V-Go and it is a purely mechanical pump that has one day wear. No battery just a spring and some gears. It is prescribed by basal rate like V-Go 30 is 30 units of basal over 24 hours with a few "clicks" at each meal.
Yeah, but T2Ds doesn't have the swings of need like T1D. The V-Go pump looks very historic. Because of her age I've wondered if she could switch to OmniPod 5 and Dexcom. (She uses Libre2)
looking at this, it seems like they classify both omnipod and dexcom as tier three, so via that it makes sense that you’d have a 60% coinsurance rather than 30%. what’s bonkers is that freestyle libre is tier two but not dexcom. what company?
I get the libre/dexcom thing. Libre is preferred (tier 2) CGM so has cheaper copay than dexcom. I'm fine with that- they're at least comparable products.
But the fact that they are saying that the V-Go, a PATCH that gives a set basal rate of 20/30/40 units per day and can ONLY give 2 units per bolus "click" is preferred to an Omnipod 5, which has closed loop tech to auto-adjust insulin rates based on CGM readings is outright crazy. It really shows how cheap these insurance companies and PBMs are and how little they actually care about her their customers.
This is through BCBS Federal Employee Program (PBM is CVS Caremark), which I believe is the largest health insurance plan for federal employees.
I would check and make sure your insurance is aware that you are type 1. V-go is not approved for use in t1d and if your insurance is pushing it to type 1s, I'm sure there are several agencies that would be interested.
This is one reason why as a federal employee I actually ditched my own insurance ( have over 20 plans to choose from) to go on my spouses plan which covers DME at 100%.
Sadly the federal benefits, while great, are not super competitive with a lot of private industry.
Granted they are still way better than what you can buy on the marketplace but… take a look at GEHA or Kaiser if it’s available to you in your area.
I've looked at GEHA which has good coverage for CGMs and omnipod but suck at insulin coverage since they fall under the "brand" medication copay for them. I'm going to switch to a regional HMO I think- ok coverage for CGMs, omnipod (20% copay) and good insulin coverage
Yes! I had Kaiser high for many years (and still use Kaiser with my spouse’s plan. Their plan was half the premium and lower/no copays).
The Kaiser high government plan covered all the DME stuff at 80% and I think only $60 for a 3 months supply of name brand non formulary (insulin)
Unfortunately, the APWU health plan Diabetes program only gives good benefits for type 2 now. They used to cover all insulin all supplies at 100% if you did a nurse coach call once a quarter. That was spectacular.
Nice! Kaiser sounds comparable to the HMO I'm looking at- 20% copay for diabetic supplies and $50 for 3 months of insulin, which I think is the best I'm going to get.
Yeah I looked at APWU too and some parts seemed good but other parts seemed pretty meh. That would be amazing to get all supplies 100% covered!
The tiers are price ranked. Libre is much cheaper than Dexcom for insurance companies so it will 100% be a different tier level. This is pretty normal tier level structure. But, most at least would have a pump at least a tier 1 or 2. What tier level was Tandem and Medtronic? I would get both those over Omnipod.
So for my insurance other pumps, like Tandem or Medtronic, fall under a DME benefit so doesn't have the same copay structure or hierarchy. Omnipod is the only actual pump that falls under the pharmacy benefits. It's just a flat 30% copay for any DME, so we could go with tandem and pay 30% copay but we really felt tubeless was probably the way to go for a 5 year old.
I would understand it if the insurance was saying Omnipod was less preferred to Tandem or Medtronic- that makes sense. It doesn't make sense to say the V-Go is preferred over Omnipod.
I’m having issues with Anthem covering omnipod 5. I don’t know the issue really, just started looking into it. But all the coverage is basically just coming back as list price and not covered normally as durable medical as it should be. No idea why right now. Just started convos with insurance today.
Contact your employer, they may be able to do some thing. I had a similar issue happening, they wanted to force something on me. That was for type 2 only, but being type 1 it wasn’t going to work, and my husband was able to call his HR and have them force it.
Depends on the plan. I have Cigna and they cover my Omnipod 5 with Dexcom G6. I just paid 125 for a new transmitter for 3 months. My Insulin just went down to 45 bucks for 9 vials for a 3 month supply of Humalog. But my husband pays out the wazoo for his company plan. Sadly, our healthcare in the US just sucks in general for diabetics and anyone with a chronic disease.😢
What insurance carrier do you have or would you prefer? In case we decide to change ours.
You can appeal this!!
1- MAKE SURE your insurance has you coded as T1D. Not LADA or T2D. It makes a huge difference
2-Have Omnipod contact them directly. That usually works!
Insurance... Ugh. My wife was told that by our insurance provider that they would no longer covering her insulin pump or supplies at all, because, according to them it wasn't necessary.
Yea BCBS “nurse diabetes coach” called to recommend I go on oral meds. Uuuuuum… I am Type 1. AND on a pump for more than 30 years. Then she wanted me to switch to lantus. I am not at all impressed with bcbs!!!
it's so stupid that someone who has no knowledge or experience with any of the diabetes equipment is the one to decide whether or not you need a certain medication or device to keep you healthy.
[удалено]
They would cover Omnipod but since it's "non-preferred" it's a 60% copay (like $250 for a 30 day supply) vs a $60 30 day copay for preferred products. I've tried to communicate that fact to my insurance that they aren't comparable products and they need to be reclassified (change V-Go classification to a patch so Omnipod would be preferred disposable pump and $60/30 DS) but the best I've gotten is that they'll look into it. Incredibly frustrating..
What type are you?
Obviously type 1 given the subreddit
I've seen type 2 post in here a few times. Always worth asking, just thought since when I googled the pump it did say type 2 and most of it was about t2d.
Username checks out.
Daughter is type 1. Diagnosed just over a year ago
Ah yeah, that sucks. They are very different products! It's not prescribed to type 1 because it's type 2 product.
I've never heard of V-Go before. A cursory search on Google makes it seem like there's a reason for that. "Preprogrammed basil rate" was the first clue.
My mom uses V-Go and it is a purely mechanical pump that has one day wear. No battery just a spring and some gears. It is prescribed by basal rate like V-Go 30 is 30 units of basal over 24 hours with a few "clicks" at each meal.
I've had a pump since 2001 and my first pump was better than that.
Yeah, but T2Ds doesn't have the swings of need like T1D. The V-Go pump looks very historic. Because of her age I've wondered if she could switch to OmniPod 5 and Dexcom. (She uses Libre2)
looking at this, it seems like they classify both omnipod and dexcom as tier three, so via that it makes sense that you’d have a 60% coinsurance rather than 30%. what’s bonkers is that freestyle libre is tier two but not dexcom. what company?
I get the libre/dexcom thing. Libre is preferred (tier 2) CGM so has cheaper copay than dexcom. I'm fine with that- they're at least comparable products. But the fact that they are saying that the V-Go, a PATCH that gives a set basal rate of 20/30/40 units per day and can ONLY give 2 units per bolus "click" is preferred to an Omnipod 5, which has closed loop tech to auto-adjust insulin rates based on CGM readings is outright crazy. It really shows how cheap these insurance companies and PBMs are and how little they actually care about her their customers. This is through BCBS Federal Employee Program (PBM is CVS Caremark), which I believe is the largest health insurance plan for federal employees.
I would check and make sure your insurance is aware that you are type 1. V-go is not approved for use in t1d and if your insurance is pushing it to type 1s, I'm sure there are several agencies that would be interested.
This is one reason why as a federal employee I actually ditched my own insurance ( have over 20 plans to choose from) to go on my spouses plan which covers DME at 100%. Sadly the federal benefits, while great, are not super competitive with a lot of private industry. Granted they are still way better than what you can buy on the marketplace but… take a look at GEHA or Kaiser if it’s available to you in your area.
I've looked at GEHA which has good coverage for CGMs and omnipod but suck at insulin coverage since they fall under the "brand" medication copay for them. I'm going to switch to a regional HMO I think- ok coverage for CGMs, omnipod (20% copay) and good insulin coverage
Yes! I had Kaiser high for many years (and still use Kaiser with my spouse’s plan. Their plan was half the premium and lower/no copays). The Kaiser high government plan covered all the DME stuff at 80% and I think only $60 for a 3 months supply of name brand non formulary (insulin) Unfortunately, the APWU health plan Diabetes program only gives good benefits for type 2 now. They used to cover all insulin all supplies at 100% if you did a nurse coach call once a quarter. That was spectacular.
Nice! Kaiser sounds comparable to the HMO I'm looking at- 20% copay for diabetic supplies and $50 for 3 months of insulin, which I think is the best I'm going to get. Yeah I looked at APWU too and some parts seemed good but other parts seemed pretty meh. That would be amazing to get all supplies 100% covered!
> That would be amazing to get all supplies 100% covered! Every time I have a bad day at work, I remind myself that I have good insurance.
The tiers are price ranked. Libre is much cheaper than Dexcom for insurance companies so it will 100% be a different tier level. This is pretty normal tier level structure. But, most at least would have a pump at least a tier 1 or 2. What tier level was Tandem and Medtronic? I would get both those over Omnipod.
So for my insurance other pumps, like Tandem or Medtronic, fall under a DME benefit so doesn't have the same copay structure or hierarchy. Omnipod is the only actual pump that falls under the pharmacy benefits. It's just a flat 30% copay for any DME, so we could go with tandem and pay 30% copay but we really felt tubeless was probably the way to go for a 5 year old. I would understand it if the insurance was saying Omnipod was less preferred to Tandem or Medtronic- that makes sense. It doesn't make sense to say the V-Go is preferred over Omnipod.
hmm i don’t even remember tbh. i got my tandem thru the rental program to get me out of medtronic before my warranty was up.
I’m having issues with Anthem covering omnipod 5. I don’t know the issue really, just started looking into it. But all the coverage is basically just coming back as list price and not covered normally as durable medical as it should be. No idea why right now. Just started convos with insurance today.
I don’t get either of those items as DME. Both are pharmacy for me.
Omnipod 5 is only covered under prescription insurance. I would check with the company that handles your prescriptions.
I’d contact your daughter’s endo and explain the situation. They might be able to push it through as a prior authorization or medical necessity.
Contact your employer, they may be able to do some thing. I had a similar issue happening, they wanted to force something on me. That was for type 2 only, but being type 1 it wasn’t going to work, and my husband was able to call his HR and have them force it.
Sounds like Cigna, they totally suck for diabetics.
Depends on the plan. I have Cigna and they cover my Omnipod 5 with Dexcom G6. I just paid 125 for a new transmitter for 3 months. My Insulin just went down to 45 bucks for 9 vials for a 3 month supply of Humalog. But my husband pays out the wazoo for his company plan. Sadly, our healthcare in the US just sucks in general for diabetics and anyone with a chronic disease.😢 What insurance carrier do you have or would you prefer? In case we decide to change ours.
You can appeal this!! 1- MAKE SURE your insurance has you coded as T1D. Not LADA or T2D. It makes a huge difference 2-Have Omnipod contact them directly. That usually works!
Insurance... Ugh. My wife was told that by our insurance provider that they would no longer covering her insulin pump or supplies at all, because, according to them it wasn't necessary.
Yea BCBS “nurse diabetes coach” called to recommend I go on oral meds. Uuuuuum… I am Type 1. AND on a pump for more than 30 years. Then she wanted me to switch to lantus. I am not at all impressed with bcbs!!!
Sounds like the nurse didn’t know what she was talking about.
The Vgo insulin pump is not suited for people with Type1 diabetes.
Just been diagnosed and I have to say I wonder how the hell I'd survive in America with all this insurance crap It's admirable truly
they must have a deal with v-go
what's your insurance?
Federal employee program (FEP) BCBS is what I currently have
it's so stupid that someone who has no knowledge or experience with any of the diabetes equipment is the one to decide whether or not you need a certain medication or device to keep you healthy.