got a call from omni pod

[realsweety]

got a call from omni pod last night.they told my husband that the insurance put it "out of net work" she started to quote that it was covered 70/30 .then she said that something didnt seem right.so she is going to do some calling around today and figure some things out.I remember reading somewhere here what it should be under but can't remember what.can somebody who has it let me know what their pod is covered under.we deffinately can not afford the 70/30.my husband was even thinking of going from bc/bs ppo to highmark bc/bs and paying the higher monthly cost so that maybe more would be coverd but I don't know.Allison really liked the pod,and right now she thinks its broken and getting fixed.(she decided that on her own)she doenst want anything else.and personaly thats what I want for her.theres is nothing wrong with the others ,but there is more reasons we love the pod than the others.thank you to anyone who may answer my ramblings lol

[etringali]

BCBS generally will pay for the PDM @ 100% and the pods at 80/20. The pods are covered under prosthetic benefits. At least, that is how it worked for us. I believe with traditional pumps, they are covered under durable medical equipment for the pump itself, and infusion sets and general supplies go under your pharmacy benefits.

[CC'sMom]

I think (hopefully someone can confirm this) that it goes under durable medical. Hopefully Insulet can help figure it out for you.

We're from PA too. The NE part of the state. Where are you from?

[taximom]

Our PDM was covered under Durable Medical Equipment (DME) 100% (after deductable), then the pods are supplies (like infusion sets). They were covered at 90%.

That's how our insurance worked.

[czardoust]

Hi Allison, I feel your pain on the cost. We're waiting on our omnipod trial, and I went ahead and ordered it, waiting til June til because that is when Kats next endo appt is, Im guessing I should hand him the medical necessity forms then for the insurance battle with Tricare. If Tricare covers it, its 80/20 which is still frikkin high (for us). Especially that first month with the purchase of the remote! $800 X 0.20 is $160, if they cover 80/20 which I have no faith in because Tricare denies whatever we ask for. We've been thru this with the CGMS. The omnipod thru tricare is considered durable medical equipment, if the rep I talked to has the right idea, she may have thought it was a traditional pump.

[rachel's mom]

We have United Health Care and they have denied us in-network coverage for the 2nd time. We first filed a GAP exception and then filed a Clinical Exception. So, we are now paying the 30% because by daughter only wanted the Omnipod and would not even consider any other pump. I will continue to appeal as I was told that UHC has approved Omnipod in network for some after several appeals. Keep trying and don't give up.

[Daniel's Mom 1993]

We also have United Healthcare and it is in appeal - they covered out of network but denied a major portion of the pods saying "above reasonable cost for similar services available in the area" Not sure what will happen may have to return everything and start over - I thought they would cover out of network and I would pay the higher deductible and percentage did not find out until after the fact what Out of network could mean so be sure to ask alot of questions - I thought II had but apparantly not. Good Luck

[Mermaid]

Does anyone know FOR SURE that their infusion sets are covered under prescription benefits and not dura-medical?
Technically they should be prescription benefits since they are disposable. Under our insurance they are not, and we max out our dura-medical cap and have to pay out-of-pocket.