The Centers for Medicare and Medicaid Services (CMS) has recognized that some insulin delivery systems may now be covered by a Medicare Part D prescription drug plan when the devices are delivering insulin directly to the body and not otherwise covered by Medicare Part B as durable medical equipment.

An example of such an insulin pump covered by Medicare Part D plans is Insulet Corporation's Omnipod® System. 

(For more information, please see diatribe.org/insulets-omnipod-now-eligible-medicare-coverage).


Insulin Pumps and Medicare Part B coverage.

Traditionally, Medicare Part B covered insulin pumps as durable medical equipment (DME) and the CMS document, "Medicare's Coverage of Diabetes Supplies & Services" notes:

“Insulin pumps worn outside the body (external), including the insulin used with the pump, may be covered for some people with Medicare Part B who have diabetes and who meet certain conditions. Insulin pumps are considered durable medical equipment. “Durable medical equipment” is certain medical equipment ordered by your doctor for use in the home.”  And adds, "Medicare Part D covers insulin that isn't administered with an insulin pump."

"Medicare Part B covers external durable insulin pumps and the insulin that the device uses under durable medical equipment if you meet certain conditions."

Insulin Pumps covered by Medicare Part D

In a January 2018 memo, CMS began to expand coverage of insulin delivery systems with new guidance that noted:

"[w]e are issuing this guidance regarding Part D coverage of products used for the delivery of insulin for the treatment of diabetes. With the introduction of new insulin delivery devices to the market, questions have arisen about Part D coverage for these products. Specifically, we have been asked whether newer insulin delivery devices that are not covered under Medicare Part B meet the Part D definition of 'medical supplies associated with the injection of insulin.'"

The CMS guidance continues on to note:

"newer insulin delivery devices in the form of both mechanical and electronic insulin pumps have become available that are not coverable under the Medicare Part B durable medical equipment (DME) benefit. Consistent with the Part D policy to allow coverage of insulin delivery devices that are 1) directly associated with delivering insulin into the body and 2) not otherwise considered DME under Part B, Part D sponsors may provide coverage of such products under Part D as 'medical supplies associated with the injection of insulin.'"

Question:  How do I find a Medicare Part D plan that covers such an insulin pump?

Unfortunately, with some difficulty.  Although insulin pumps like the Omnipod® can be prescribed by your doctor, the Medicare Plan Finder (as of 08/08/2023) does not include this insulin pump in their drug data - and so you cannot add this device to your drug list when searching for a Medicare Part D or Medicare Advantage plan.

As a note, our Medicare Part D Drug Finder (Q1Rx.com) will search for drug coverage across all Medicare Part D plans in an area alphabetically or by National Drug Code (NDC) - an 11-digit system to uniquely identify a drug.  However, at this time, although you can get a prescription for insulin pumps such as the Omnipod, there is no data or NDC for this “delivery system” included within our formulary data.  And although, like syringes used for the delivery of insulin, non-DME insulin pumps may be covered by your Medicare Part D plan, you will need to look closely in the plan's printed information or contact your plan's Member Services department to learn more about coverage and cost.

Therefore, it is difficult (without contacting every Medicare Part D drug plan in your area) to systematically search for a Medicare Part D plan that covers this device.

On a positive note, the Omnipod® site provides some additional direction for working with a Medicare Part D plan that has not yet added this device to their list of covered drugs:

"Unlike pharmaceutical products, Omnipod will not appear on Medicare's plan finder site since it is a medical device."

At the current time, the Omnipod® System is covered on the following Part D plans under a Tier 3 and Tier 4 copay benefit. These may be the most cost-effective options for your Omnipod prescription

Part D coverage for Omnipod® 5 Automated Insulin Delivery System:

• Cigna- All PDP and Advantage plan offerings (Preferred-Tier 3)
• Humana Gold, Community, and Choice Advantage Plans (Preferred-Tier 3)
• Aetna SilverScriptPlus (Preferred-Tier 3)
• Elixir- All plan offerings (Non-Preferred-Tier 4)
• Wellcare- All PDP and Advantage plan offerings (Non-Preferred-Tier 4)
• MedImpact Medicare (Non-Preferred-Tier 4)

Part D coverage for Omnipod DASH® Insulin Management System:

• AARP MedicareRx Preferred (PDP) and MedicareAdvantage (Preferred-Tier 3)
• AARP Medicare Advantage Plans 1, 2, 3 (Preferred-Tier 3)
• AARP Medicare Advantage Choice (Preferred-Tier 3)
• Cigna- All PDP and Advantage plan offerings (Preferred-Tier 3)
• Humana Gold, Community, and Choice Advantage Plans (Preferred-Tier 3)
• Aetna SilverScriptPlus (Preferred-Tier 3)
• Elixir- All plan offerings (Non-Preferred-Tier 4)
• Wellcare- All PDP and Advantage plan offerings (Non-Preferred-Tier 4)
• MedImpact Medicare (Non-Preferred-Tier 4)

(https://www.omnipod.com/is-omnipod-right-for-me/coverage/medicare 08/08/2023)

You can read more about the formulary exception process here:
q1medicare.com/PartD-DrugListExceptionAppealGrievance.php