Does Medicare Cover Omnipod? Part D Costs and Models

Yes, Medicare does cover Omnipod, but through Part D prescription drug plans rather than Part B durable medical equipment. That single distinction shapes everything else: how you get the pods, what you pay, and which rules apply. Coverage is available with a prescription for people with type 1 diabetes ages two and older and type 2 diabetes ages 18 and older.

Why Omnipod Sits Under Part D, Not Part B

Most insulin pumps are covered by Medicare Part B as durable medical equipment. Omnipod isn’t, because its insulin-delivering pod is disposable and replaced every two to three days. Medicare’s definition of “durable” requires equipment to withstand repeated use and last at least three years, and the pods can’t meet that bar.¹

In January 2018, CMS classified Omnipod as a “medical supply associated with the injection of insulin,” a category that federal law allows Part D plans to cover.² Insulet, Omnipod’s manufacturer, then contracted with individual Part D carriers to add the device to their formularies.³

What Part D Coverage Changes for You

Because Omnipod is a pharmacy benefit rather than DME, several things work differently than they would with a traditional pump.

You pick it up at a retail pharmacy or receive it by mail order, not through a DME supplier.⁴
There’s no four-year lock-in. Part B pumps come with a four-year commitment; Omnipod doesn’t, so you have more freedom to switch devices.⁵
No C-peptide test is required. Part B insulin pump coverage hinges on that lab result; Part D coverage of Omnipod does not.⁶
Omnipod isn’t part of Medicare’s DMEPOS competitive bidding program, which sets pricing and supplier access for Part B pumps.⁷

Which Omnipod Models Are Covered

Omnipod 5, the current automated insulin delivery system, has broad coverage across Part D plans.⁵ Both Omnipod 5 and Omnipod DASH appear on formularies of plans that cover the product line, usually at Tier 2, Tier 3, or Tier 4.⁸ Which model your plan includes depends on that plan’s specific formulary, so confirm before ordering.

What You’ll Pay

Out-of-pocket costs vary by plan because each Part D plan sets its own formulary tiers, copays, and coinsurance rates. A few broad protections apply across the board.

Beginning in 2025, the Inflation Reduction Act eliminated the Part D coverage gap and added an annual out-of-pocket cap. For 2026, the cap is $2,100.⁶ Once your true out-of-pocket spending on covered Part D drugs and supplies hits that threshold, the plan pays 100% of covered costs for the rest of the year. You can also opt into the Medicare Prescription Payment Plan, which spreads your annual cost-sharing across monthly installments instead of collecting it at the pharmacy counter.⁵

Many Part D plans have moved brand-name items like Omnipod from flat copays to coinsurance, meaning you pay a percentage of the device’s cost rather than a fixed dollar amount.⁶ The $2,100 cap still applies either way.

One important boundary: the $35-per-month insulin copay cap covers insulin only, not the pods. CMS treats the disposable pump as an “insulin supply,” a separate category from the insulin itself, so your pods carry their own cost-sharing under the plan’s formulary.⁹

If You Qualify for Extra Help

Beneficiaries who qualify for Medicare’s Extra Help program (the Low Income Subsidy) pay much less. In 2026, they pay no plan premium, no deductible, and no more than $5.10 per generic or $12.65 per brand-name drug. After total drug costs reach $2,100, they pay nothing for covered drugs for the rest of the year.¹⁰ Insulet confirms that for dual-eligible patients and those receiving the low-income subsidy, 2026 Omnipod copays range from $0 to $12.65.⁷

Medicare Advantage Plans

Medicare Advantage plans (Part C) that include drug coverage handle Omnipod through the same Part D pharmacy benefit framework. Carriers known to cover Omnipod 5 include United/AARP, Healthspring (Cigna), Humana, and Anthem, though you should always verify with your specific plan.⁵

How to Confirm Your Plan Covers It

Checking Omnipod coverage isn’t as simple as looking up a prescription drug. Because it’s classified as a medical supply, it usually doesn’t appear in the Medicare Plan Finder on Medicare.gov and has no standard National Drug Code in many search databases.⁸ Absence from those tools doesn’t mean the plan won’t cover it. You just have to check another way:

Call your Part D plan’s Member Services and ask about Omnipod under Part D benefits, not DME or Part B.⁵
Use Insulet’s coverage lookup tool and free benefits check on the Omnipod website.
Contact an Omnipod Medicare Specialist for benefits verification and prescription coordination.
Call 1-800-MEDICARE (1-800-633-4227) for plan-level questions.⁷

Prior Authorization and Formulary Exceptions

Some Part D plans list Omnipod on the formulary and need only a prescription. Others require prior authorization first, with clinical criteria that can include a diabetes diagnosis, an insulin regimen of three or more injections a day, and either four-times-daily blood glucose testing or continuous glucose monitor use. Approvals typically last 12 months and can be renewed if the patient shows clinical benefit.¹¹

If your plan doesn’t list Omnipod on its formulary at all, you can request a formulary exception. Every Part D plan must have a process for these requests, and your physician can submit a Medicare Formulary Exception/Coverage Determination Form on your behalf.⁷ Insulet’s partner pharmacy, ASPN Pharmacies, helps with exception and prior authorization submissions and offers a free coverage check when a prescription is sent to them.⁶ Providers can also start electronic prior authorization through CoverMyMeds. Once approved, the prescription can go to your preferred retail pharmacy or to ASPN’s network for home delivery.¹²

If an exception request is denied, you have the right to appeal through the standard Part D appeals process.

1
U.S. Government Accountability Office. Medicare: CMS Should Evaluate Providing Coverage for Disposable Medical Devices That Could Substitute for Durable Medical Equipment
2
Centers for Medicare and Medicaid Services. Medical Supplies Associated With the Injection of Insulin
3
Insulet Corporation. Medicare Part D Prescription Drug Plans May Now Cover Omnipod
4
diaTribe. Insulet’s Omnipod Now Eligible for Medicare Coverage
5
Omnipod. Omnipod Medicare Coverage
6
Omnipod. Omnipod HCP Reimbursement – Medicare
7
Omnipod. Omnipod HCP Medicare FAQ
8
Q1Medicare. Will My Medicare Part D Plan Cover My Insulin Pump
9
Centers for Medicare and Medicaid Services. Frequently Asked Questions – Medicare Part D Insulin Benefit
10
Medicare.gov. Get Help With Drug Costs
11
Blue Cross NC. Insulin Pump Patch Prior Authorization Criteria – Medicare Part D
12
ASPN Pharmacies. ASPN Pharmacies FAQ