01/30/2024
Updates
The Insulet Corporation which manufactures Omnipod has created and marketed the new Omnipod 5 for individuals with type I diabetes with the restriction that it is only available through retail pharmacies.
Upon the Centers for Medicare & Medicaid Services (CMS) approval, the Texas Health and Human Services Commission (HHSC) will complete the process of adding Omnipod 5 to the Vendor Drug Program (VDP) formulary. While HHSC continues to work with CMS and is seeking an expedited review, it is possible that CMS will not provide approval and VDP will not be able to add Omnipod 5 to the VDP formulary by Dec. 31, 2023. Blue Cross and Blue Shield of Texas may not cover Omnipod 5 through the pharmacy benefit until VDP can add it to the formulary.
Until CMS approves, HHSC has identified an alternative method of coverage to ensure Medicaid members have access to Omnipod 5 after Dec. 31, 2023, if CMS approval is not received before Jan. 1, 2024. HHSC requires BCBSTX to provide all medically necessary services under:
- Early, Periodic, Screening, Diagnostic, Testing (EPSDT), also known as Texas Health Steps, or
- “Home Health DME and Supplies Exceptional Circumstances” (Exceptional Circumstances) policy.
Billing Information
Existing Omnipod Eros/Classic users are allowed access to the updated Omnipod models through the ESPDT and the Exceptional Circumstances policy by waiving the three-year device replacement waiting period due to lack of availability of supplies for the original model.
The alternative tubeless external insulin pump (Omnipod) should be billed using the external insulin pump code E0784 with a U1 modifier and A9274 for its disposable pod including all supplies and accessories.
Resource
- Home Health Durable Medical Equipment and Supplies Exceptional Circumstances Provision Questions and Answers
- Home health Durable Medical Equipment and Supplies Exceptional Circumstances Provision
- Coverage of Services Not in the TX-MCD SP
- 2020 1214 - Services Not Covered in the Texas Medicaid State Plan
The above material is for informational purposes only and is not a substitute for the independent medical judgment of a physician or other health care provider. Physicians and other health care providers are encouraged to use their own medical judgment based upon all available information and the condition of the patient in determining the appropriate course of treatment. References to other third-party sources or organizations are not a representation, warranty or endorsement of such organization. Any questions regarding those organizations should be addressed to them directly. The fact that a service or treatment is described in this material is not a guarantee that the service or treatment is a covered benefit and members should refer to their certificate of coverage for more details, including benefits, limitations and exclusions. Regardless of benefits, the final decision about any service or treatment is between the member and their health care provider.