So I have been talking to some people on here about their Omnipods and the more I here about it the more I think that I want it. I called up my endo and he told me i was responsible for calling my insuance company and seeing how much of it they cover. Well to make a long story short I spent 30 minutes on the phone while my insurance company gave me a run around just to find out that they won't cover any of it. I wanted to yell at them that this would probably save them money in the long run because of all the severe lows I have been having with the Lantus I am sure to be in the hospital eventually. but I kept my cool, lol. anyway my question for you all is have any of you experienced your insurance company not covering the Omnipod? I have United Healthcare
Hi Julia -
This is a pretty recent development, but United Healthcare is now covering Continuous Glucose Monitors. There is a link on this page: http://www.jdrf.org/index.cfm?page_id=104576 that connects to the UH policy concerning CGMs: https://www.unitedhealthcareonline.com/b2c/cmaIndexResult.do?channelId=016228193392b010VgnVCM100000c520720a____&htmlFilePath=/ccmcontent/ProviderII/UHC/en-US/Assets/ProviderStaticFiles/ProviderStaticFilesHtml/MedicalPolicies/Continuous_Glucose_Monitoring_for_the_Management_of_Diabetes_Mellitus.htm
It looks like your endo just needs to back you up with the following:
"Long-term continuous glucose monitoring (greater
than 72 hours), for improving glycemic control, is proven as a
supplement to self-monitoring of blood glucose (SMBG) for type 1
diabetes patients who meet EITHER of the following criteria AND have
demonstrated adherence to a physician ordered diabetic treatment
plan:
- Have been unable to achieve optimum glycemic control
as defined by the most current version of the American Diabetes
Association (ADA) Standards of Medical Care in Diabetes
OR
I'm confident you and your doctor can document times you've gone low without realizing it (anytime you go below 60 mg/dl and test, you weren't aware of it, right?)
Try again. And tell your endo you will need their help...
Katie,
The Omnipod is an insulin pump, not a CGM. I had Cigna deny mine until I appealed it. I don't think there is any debate left about the value of pump/CSII therapy. I would suspect that the insurance company's refusal in this case puts them on very shaky legal ground since they are covering all other FDA approved insulin pumps. I would be hesitant to recommend the Omnipod to most other users - but really, in this case, the point is that it is pump therapy, period.
Cheers!
A-D
Ah, yes. I knew that. Just got going on the CGM part of United Healthcare. Sorry about that.
Kay - you can find United Healthcare's External & Implantable Pump Therapy Medical Policy here: https://www.unitedhealthcareonline.com/b2c/cmaIndexResult.do?channelId=016228193392b010VgnVCM100000c520720a____&htmlFilePath=/ccmcontent/ProviderII/UHC/en-US/Assets/ProviderStaticFiles/ProviderStaticFilesHtml/MedicalPolicies/External_and_Implantable_Insulin_Pumps.htm
Like A-D, I'd question how they can cover select FDA approved pumps but not others.
Good luck. Appeals are a way of life for someone with type 1. Get your facts, site their policies, and get your doctor to back you up (they can write a letter and give you a copy of your test results).
I will definately appeal this matter asap. I was so depressed earlier but now I feel hopefull. thank you guys.
A-d
why would you be hesitant to recomend the omnipod?
Really, telling my insurance company that the pump would save them money by keeping me out of the hospital actually worked, at least they paid attention to what I had to say after I said that.
On a slightly different topic-
I've used the same phrase when dealing with insurance at the pharmacy- one day I was out of insulin (I had managed to break my last vial) and I needed insulin early. I got a big, "The insurance company will not pay for this because the order is early."
My reply was "Then tell them that my hospital bill from going into DKA will be much higher then them giving me a measly bottle of humalog early."
The pharmacist gave me the look and repeated the phrase into the phone, she then smiled, "They said they'll cover it." She said holding back a chuckle.
ahhh, harsh reality- it can be funny when you win
I am having the issue of insurance only doling one vial Apridra via insulin pump) out at a time. Not much wiggle room for error. How have other people gotten more than one vial at a time? Not to mention how am I supposed to keep one with me when I am out doing field work, and have a back up in the fridge in case anythig happens to the one I have? I know I need to call then it is just so easy to get burned out by that aspect alone!
I have heard of some companies not covering the omnipod, but covering all other pumps. I don't know why -- because it's newer? because it works slightly differently?I heard about that last year, but maybe it's still going on...
According to some people I've talked to, the Omnipod can have malfunctions (maybe they're still working out the kinks?), but other people I've talked to really liked it.
Have your called the company that makes the pump? They'll want to help you get it covered to get your money, so they'll often give you advice on insurance issues.
So I posted this in another string, but have found it to be a very useful tactic when dealing with insurance, any other tips I would love to hear!
One tip I have received was to have a notebook designated for those calls to insurance or medical companies. When calling jot down the time, date, and when the representative answers ask their name and write it down. During your conversation write down what you talked about and make it clear you are doing so, if you need to ask 2x to clarify- do it. You may still get the run around the first call or so, but when you have to call back repeatedly and tell them when you had called last (exactly) and who you talked to and what you talked about, sometimes you can break through. It is super annoying for sure! But whenever I find I am having issues, this is the best approach plus you gotta use your stern voice ( I am very soft-spoken, but have an insurance voice), and tell them what the consequences of their neglect are, and ask for a viable solution from them. If they continue you may want to consider contacting an diabetes advocate group.
I used this when minimed lost a payment of mine for a pump, and I had creditors calling (they called and admitted it was their fault later). Also when insurance thought I was dead- I wasn't I was on a road trip very much alive! And when they wouldn't cover various things, or withdrew money out of my account after I had cancelled that particular coverage. Sometimes it works great, others not so much, but it makes me feel less futile and like I am trying my hardest.
My daughter uses Novolog in her Minimed. She is only 7 and uses about 12 units a day so we were throwing out most of the bottle of the 'Log at the end of 30 days. Our solution has been to use the Nololog pen fills. They are smaller--you get 5 penfills in a box for one copay. The penfills don't fit snugly on the reservoir filling apperatus needle when filling the pump reservoir but you can make it work. This would not work for you if you used a great deal more insulin than we do or if Apidra does not come in penfills. We always have extra at the end of ever month and have small vilas to take with us on trips etc...