How to Fill Out and Submit the Omnipod Financial Assistance Application

Insulet’s Financial Assistance Program can reduce or eliminate your out-of-pocket cost for Omnipod DASH and Omnipod 5 pods, and to apply you need to request the application from Insulet, gather income documentation, have your prescriber sign the medical section, and submit the completed package for review. There is no public download link for the Omnipod financial assistance application, so the first step is a phone call or online contact request. If approved, you receive an electronic copay card that covers your copay, deductible, or co-insurance on one 30-day pharmacy fill per month for up to 12 months.¹

How to Get the Application

The form is not posted as a standalone download, and Insulet may update it periodically. Call Insulet customer care at 1-800-591-3455 or use the contact form at myomnipod.com to request a copy.¹ Your prescribing doctor’s office may also have copies on hand; Insulet’s prescriber materials point providers to the same phone number.²

Who Qualifies

Before you spend time on the paperwork, confirm you fit the program’s basic terms.

Residency and Prescription

You must be a U.S. resident with a valid prescription for Omnipod DASH or Omnipod 5 pods. Residents of all 50 states, Puerto Rico, and the U.S. territories are covered.¹

Insurance Status

The program is aimed at people who are uninsured, whose insurance does not cover Omnipod, or who cannot afford the out-of-pocket share their plan leaves behind.¹ Some commercial plans are still excluded at Insulet’s discretion, reviewed case by case.

One hard disqualifier: if Medicare, Medicaid, or any other federal or state program pays for any part of your Omnipod prescription, you cannot participate. Insulet follows federal rules that prohibit applying manufacturer savings to government-funded prescriptions.³ That rule sweeps in Medicare Part D. If you enroll in a government program while using the copay card, you must call 1-800-591-3455 to stop participation immediately.¹

Pharmacy Channel

Your prescription must be filled through a retail or mail-order pharmacy. If your pods come through the durable medical equipment (DME) channel or the pharmacy DME channel, the copay card does not apply.¹ If you are unsure how your pods are billed, ask your pharmacy or plan before applying.

Financial Need

You must show financial need based on income criteria Insulet sets. The company does not publish its specific threshold, so income eligibility is determined during review of your documentation.

What to Gather Before You Fill It Out

Pulling these together in advance keeps the process from stalling:

A clear photocopy of a government-issued photo ID (driver’s license, state ID, or passport).
Income proof. Your most recent IRS Form 1040 is preferred. If you did not file, W-2s or your last three consecutive pay stubs work. Social Security benefit letters and unemployment records are also accepted.
Your total household size, which Insulet uses alongside income to assess need.
Insurance details if you have pharmacy coverage: the Bin, PCN, and Group numbers from your card. If uninsured, you will mark that on the form.
Prescriber information: your doctor’s name, practice address, phone number, and National Provider Identifier (NPI). Your provider also needs to sign the medical section.

Mismatches between the form and the supporting documents are one of the most common reasons applications get held up. Check that the income you enter matches the tax return or pay stubs you attach. The application requires “true and correct information,” and inaccurate data can disqualify you from the program.¹

Filling Out the Key Sections

Personal and Contact Information

Enter your legal name, date of birth, mailing address, phone, and email exactly as they appear on your ID. Reviewers may reach out by phone or email if they need clarification, so give contact information you actually check.

Financial Information

Report total household income and household size, then attach the supporting documents. If your finances have changed since your last tax filing, for example after a job loss, include current pay stubs or an unemployment statement alongside or instead of the older return.

Insurance and Pharmacy

Copy the Bin, PCN, and Group numbers directly from your pharmacy insurance card. These fields let Insulet verify that your plan does not already cover Omnipod or that your remaining costs are unaffordable. If you have no insurance, mark the form accordingly. If Insulet cannot verify your coverage status from what you provide, they may request additional documentation before processing.

Medical Certification

A licensed healthcare provider must sign the medical section, confirming your diagnosis and the clinical appropriateness of the Omnipod system. You cannot complete this part yourself. Bring the form to your next appointment or send it to the office in advance so staff can complete and return it without a separate visit.

How to Submit

Once every section is complete and your documents are attached, send the package to Insulet. The company’s patient forms have historically accepted submissions by toll-free fax at 877-467-8538 or by mail to Insulet Corporation, 600 Technology Park Drive, Suite 200, Billerica, MA 01821. Submission instructions can change, so confirm the current method with customer care at 1-800-591-3455 before sending, especially if your form does not list a fax number or mailing address.

If you mail the application, use a service that provides tracking. The packet contains personal, financial, and medical information, and a trackable delivery gives you proof of receipt.

After You Apply

Insulet reviews the application and notifies you and your healthcare provider of the decision. The program terms do not publish a turnaround time, so if a few weeks pass with no response, call 1-800-591-3455 for a status check.

Approved applicants receive a copay card delivered electronically. It covers your eligible out-of-pocket costs, whether copay, deductible, or co-insurance, on Omnipod DASH or Omnipod 5 pods each time you fill your prescription at a pharmacy. Each card is valid for one 30-day fill per month and expires after 12 months.¹ If you still need help after that year, you reapply.

Insulet reserves the right to change program terms, eligibility criteria, or card benefits at any time without notice.¹

Common Reasons Applications Are Denied

Insulet does not publish a formal rejection list, but the program terms make several disqualifiers clear:

Any coverage under Medicare, Medicaid, or another federal or state program.¹
Receiving pods through the DME or pharmacy DME channel instead of a retail or mail-order pharmacy.
Enrollment in certain commercial plans that Insulet excludes at its discretion.
Incomplete or inconsistent documentation, including missing income proof, an unsigned medical section, or a figure on the form that does not match the attached records.
Enrollment attempted by a health plan, specialty pharmacy, or pharmacy benefit manager that Insulet has not specifically authorized to enroll patients.¹

If your application is denied and you believe it was based on incorrect information, contact customer care to ask what specific documentation would support reconsideration.

Reporting Changes During the 12 Months

Approval carries ongoing obligations. You must notify Insulet if your finances, insurance, or prescription change during the coverage period. Call 1-800-591-3455 if any of these happen:¹

You enroll in Medicare, Medicaid, or any state program. Stop using the copay card immediately.
Your household income rises to a point that could push you above the eligibility threshold, whether from a raise, a new job, or another change.
You gain new commercial coverage, lose existing coverage, or your plan’s terms change, including accumulator adjustment or copay maximization programs.
You switch products or pharmacies.

Failing to report these changes can result in losing copay card benefits retroactively.

What the Card Does Not Cover

The benefit applies only to Omnipod DASH and Omnipod 5 pods filled through a pharmacy. It does not cover the compatible continuous glucose monitor (CGM) sensor. Omnipod 5 in automated mode requires a Dexcom G7 or G6 sensor, prescribed separately, and Dexcom is not part of Insulet’s program.² Dexcom runs its own patient assistance and savings programs, so ask your provider or check Dexcom’s site if CGM cost is also a concern. The Omnipod starter kit and controller hardware are not covered separately by the copay card; the benefit is specifically for the monthly pod fills.

1
Omnipod. Financial Assistance Program
2
Omnipod. A Simplified Way to Prescribe Omnipod 5
3
Omnipod. Omnipod Cost, Coverage and Access