I was diagnosed in March 2019. I started using the Omnipod Dash system in July 2019. My second shipment of supplies was ordered in November 2019, but was 100% covered by insurance because I had met my out-of-pocket maximum by then.
I just received my bill for my first reorder of 2020 (30 pods) and it cost over twice as much as my initial supply order (PDM + 40 pods). I called my insurance company and my benefits did not change January 1st. I left a message with Omnipod, but have yet to hear anything back.
I was wondering if anyone else has had this large of an increase in cost for less supplies with Omnipod/Insulet? Maybe you could shed some light on Insulet’s allowable amounts for 2020. I am baffled at this increase, since the quote I was given upon signing on played greatly into my making the choice I did.
Hi @Dev_Renae Devin, I don’t know if this is going to help. If this is “mansplaining” I apologize
Typically, medical product companies and drug manufacturers only set list price. Nothing else. The list price in the US is inflated, because of the way insurance works.
Insurance companies divide medical products into prescription (drugs and consumables) and Durable Medical Equipment (DME) and have usually independent deductible percentages. For example my deductible is 1000, but if I were to order pods, my copay is 20 for 3 months because my insurance policy considers the pod “pharmacy “. If I order a new Medtronic pump, my part is 1800 right off the bat because it’s DME and I am liable for the complete deductible PLUS a percent of the list price.
Insurance policies are complex and while something may be covered, your copay, coinsurance, and percent deductible are determined by some form of alchemy by your insurance company.
Your issue could be that when you initially ordered you had hit your deductible. Then for your second order you had hit your maximum Out of Pocket and that is why it was fully covered.
And now why it is twice as much is you are paying your deductible for the year as it is the beginning of the year again. And once the deductible is paid it will go back to your normal co-pay then your 100% coverage until 1Jan 2021.
The issue you are having sounds very similar to my experience years ago. I had met my deductible prior to my pump purchase. The insurance did not disclose this fact to the pump company and they told me my stuff was covered at 100% and it was until the next year, and being a very young adult I didn’t question it. The next January when I got my supply bill I was very upset. Unfortunately the only person who can sort out your coverage is you. If you did not have any changes in January you might be seeing the correct cost or Insulet may have not billed it correctly for the best coverage based on your needs. You need to contact your benefits coordinator and go through everything you need with them and find out if you get any better pricing. Many people don’t know that just a small change in the billing codes can substantially change your out of pocket costs.
I’ve been known to conference in my insurance and a rep from my supplier to figure out why my charges were different from what I understood from my coverage. I’ve tried it on my own - sometimes with success - but sometimes insurance stays talking about how the claim needs to be submitted and I realize I’m over my head. Personally I’ve found having the pros go over the details is more efficient. Either they are able to resolve the issue (possibly coding as you mentioned) or can explain my financial responsibility in a way I can understand.
Wishing you the best.
