My husband is in the military and so we are covered under Military health care – Tricare. We have been transferred out West in California and fall under Triwest.

I am a type 1 diabetic and have been for 37 years. I used the Insulet Omni pod pump and it has helped me keep my blood sugar in excellent control. However, when we first arrived, the Medical Director of Triwest denied my insulin pump supplies stating it was not a necessity. I had to go and fight for my supplies.

This month is the month that I get my 3 month supply of pump supplies. My referral came back “not approved”. I called to find out why and was told that the Medical Director of Triwest denied it. Upon further investigation I found out that the Director deemed the Insulet Omni pod pump a “luxury” and could be used for gestational diabetic (pregnancy) on special cases. I was told to switch to another pump with no suggestions! Apparently this decision was made in June 2009. No notice was sent out to let me know of this change. As a result, I have less than a month of pump supplies and no idea of what pump I have to switch to that would be approved by the Director.

Switching to another pump would cost at least $6,000.00. I don’t understand why I need to switch pumps if all I need are the supplies and not the pump itself. Tricare North and Tricare South approve the Omni pod and it is only here in the West that it is not, thanks to the Medical Director. How can an insulin pump be a luxury?? It is what keeps me alive.

The Medical Director is willing to let me have only one month supply of my pods and after that he told me to find another pump!! This is a terrible waste of the taxpayer’s money!!

Nothing will change without others speaking out to the Medical Director of Triwest in Arizona. I have the mailing address and a contact number to the AZ headquarters. I have already contacting a California Congressman who is interested in this situation.

Please contact me and we can make a difference. I don't want to go blind or have kidney failure due to someone stating this pump is a luxury item.

Sound off!!!
GiGi Brakeville

First of all, do keep in mind that you won't go blind or have kidney failure if you have to resort back to insulin shots. Will it suck and take LOTS more time and attention - absolutely, but a large amount of people still use them.

With that said, have you checked Tricare's formulary website? There are specific brands of pumps, insulin supplies, etc. that are 100% covered by Tricare. It may be an unfortunate circumstance that the brand you use was once covered and now isn't. Reference the website (or call Tricare directly and ask for a name), then take that information to your doctor immediately. Worst case scenario, you have to stay on shots. Best but still not great scenario, they switch out your pump with a different brand. If Tricare wants to eat that cost, let them.

Do keep in mind that again, a pump IS a luxury to many people. They are expensive and not everybody can afford it. This may be their bottom line with you, so I'd prepare for it. I know a few people who have pumps under Tricare, but not in the West region. Contacting a Congressman/woman, in my opinion, shouldn't be your current resort. First, you should contact the Tricare formulary list, see what IS accepted (if anything), and try to get that approved. Obviously you're on a time crunch, so get in contact with your doctor to see if you can get this resolved quickly.

Here's a list of the brands/generics of covered supplies (this doesn't include pumps):

http://www.tricareformularysea...%2C30000141&dxid=604

thank you! I appreciate your reading my post and helping!

Hi Gigi,

I have an insulin pump, too, and if I had to switch brands, I know I'd be upset.

However, if there are pumps out there that Tricare West will approve, than I say go for it. It's frustrating, aggrivating, arrrgh!! alot of us can relate to being down that road with Tricare (or any health insurance company for that matter)... but you've gotta take what you can get. Who knows, maybe the model they approve will be even better for you?

I'd be curious to know the outcome, if you don't mind sharing... good thing for all of us pumpers on Tricare to be aware of!

Hi and thanks for your response. what is very odd and a lot of people I have spoken to on pumps out west here is that triwest, no matter who you speak to, cannot say what a standard pump is. we also received no notification that this change was coming so most of us where down on supplies when they denied it. It is really bad. I like my pump. what type do you have? I am trying to fight this. The medical director who signed this is the same one who denied my pump supplies when we tranferred here stating that I did not need them! This guy is a freakin moron to say the least. what type 1 diabetic doesnt need insulin pump supplies. and did u see the last response I got? the lady said it was easy to go back to shots! Obviously not a diabetic or even knows one. Thank you the most positive response I have gotten on this site and God Bless you! :0)
GiGi

Thanks very much, I can read your response, and you are completely misquoting me. I didn't say it was easy to go back to shots - I said that you wouldn't die or suffer irrevocable damage/illness if you had to use shots instead of your pump, and if for some reason Tricare pulled authorization for pumps completely (which thank goodness they are not), I'm sure that would be their logic. I actually was friends with a young girl who was one of the first to be approved by Tricare for a pump several years ago (type 1 diabetes) - it was a HUGE deal, insurance companies have come a long way since then.

Again, the thing to take notice of here is that there's not necessarily a standard pump, it's that Tricare West and Omnipod have obviously decided to end their partnership (for lack of a better word) for whatever reason, the most realistic being finances. As bethfullofwonder mentioned, better to have a pump than not, so if it means switching brands, it may be the biggest pain in the butt but if Tricare wants to pay for you to get a totally new unit, then they can waste away their money how they see fit (doesn't make sense to me, but nobody at Tricare is asking my opinion). It would be better to deal with that than to lose the option of a pump at all, from what I have heard from people who do have diabetes, including yourself/what you have just said here.

I'm sure you have enough experience with Tricare to know that the best way to get things done is to keep pursuing the matter. As I mentioned before, what you need to do is sit down with your doctor, go over the different options, then go to Tricare and ask if it will be covered or not. Tricare isn't going to hand feed you anything, I've only used 2 of the regions/contractors, but it doesn't seem to be in the nature of ANY insurance company. They won't make it easy for you, you're going to have to do the legwork, and your endocrinologist should be able to help you with that. There may even be an office manager who could help with the correspondence with Tricare to make your life easier and less complicated (and can be a level headed third party).

Gigi, Sorry for not replying sooner.

I have the Paradigm from Minimed/Medtronic and I've never used anything else to compare it to, but it's a great product. You'd have to get used to the tubing, I guess.

I don't know if you know about the continual glucose monitoring system that Minimed has now, but it works with the pump. Tricare South will pay for it! I'm getting mine this week, actually.

I'd say that's one huge benefit that the Omnipod doesn't offer. Maybe Tricare West will approve both for you to? Definitely worth looking into, if you haven't already.

Hi
Thanks for emailing me back. Triwest absolutely will not approve the Continous Glucose System. They have not even said what "standard pumps" they are approving. On a happy note, I have managed to get a Congressional investigation started and have a few higher up contacts. I have been approved for my OmniPod supplies and I have been told the policy is being rewritten. It is good to know that I not only helped myself but others as well. Thank you for being supportive and telling me about the minimed. I will keep that one in mind as well.

GiGi ;0)

That's great that you were able to stick with your omni and get your supplies! Kudos to you! And best of luck with the rest. I'm glad it turned out well.

Hi gigi98! You don't know how happy I am to read your posts. I, too, am an OmniPod User that was denied supplies as of Aug/Sep 2009, after a year that TRIWEST had approved the system. I've been talking to TRIWEST and OmniPod/Insulet Reps and had "zero" luck. All TRIWEST could suggest is that I told my Doc to request an insulin pump switch to something that would be approved. And like you, the OmniPod worked great for me - my last 3 A1c Tests were 6.5 or lower. I had also tried to contact my Congresswoman, but still have not received a response. My husband told me that I was, probably, not persistent enough, and to keep trying...
On your last post, you mentioned "I have been approved for my OmniPod supplies and I have been told the policy is being rewritten." So should I contact OmniPod and have them re-send a new request for supplies to TRIWEST? I've been back on Insulin Shots for the past month, and I can clearly see that my levels are once again "out of whack"...

Hi! I am wondering still where TriWest is going with this. I have been working to try and get this policy changed. First, please email me privately Its best to friend each other and share emails that way. for yoru PERSEC we do not allow emial addies to be posted. lots of whackjobs out there. as I have a list of cntacts that you can work on. Also, your husband is right, persistance pays and don't listen to anyone who is telling you it can't be done and that you should just "accept" what they are saying. I am not going to post publicly what I have found out but I can help you. Did you file an appeal? Within 3 days of my denial letter I have a 7 page report with documentation on why I needed this. A lot people don't understand that switching pumps or back to needles play serious havoc with our blood sugars and can cause damage.

Please....again...email me and I will do everything I can to help you ok?
In the meantime, stay strong and don't give up. Everyone told me I would NEVER get my supplies...and I am just one voice! :0)
GiGi

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