Employer-Sponsored Health Plans:
Make Them Work for the Diabetes Care You Need
Helping Employer-Sponsored Health Plans
Better Meet Diabetes Care Needs
If your employer-sponsored health insurance does not cover the therapies, devices and care you need for your diabetes, there are steps you can take to advocate for yourself (or your family member) and potentially improve your available options. Managing diabetes can be expensive without adequate insurance coverage, but by using the resources on this site you can educate yourself and feel empowered to speak with your employer or Human Resources department about finding ways to access the affordable, high-quality care you or your family member needs.
Are You Ready to Take Action?
Take action now to advocate to your employer or human resources department to demand access in the pharmacy to the Omnipod® 5 Automated Insulin Delivery System.
1. Click below to download 3 possible letter templates for employees living with type 1 diabetes (T1D) or the family member of the employee living with T1D: Choose the letter template that matches your situation.
2. Customize the letter template with the actions you have already taken to request coverage and with your or your family’s daily challenges of living with and managing T1D.
3. Send this as a letter or an email to your employer or HR department.
Download the Letters
Omnipod 5® is for patients with type 1 diabetes 6 years and older.
Tips for Advocacy:
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Introduce yourself
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Be emotional, but not angry (Often an employer is unaware that they are not including coverage for a new type of diabetes therapy)
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Keep your message concise, yet friendly and firm
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Once you have established HIPAA protections are in place with your Human Resources contact, and if you feel comfortable doing so, briefly describe your diabetes diagnosis and treatment challenges, including any avoidable costly procedures or medical treatments resulting from lack of access to necessary care
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Share details about why your current treatment is no longer optimal, as well as how the new treatment will improve your health and lifestyle
- Be specific about the product you are inquiring about by including its National Drug Code (NDC)* in your description (the NDC for the Omnipod 5 G6 Intro Kit is 08508-3000-01 and NDC for the Omnipod 5 G6 Pods is 08508-3000-21)
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Share details of your medical history to show you are a good candidate for this therapy
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Be firm that you are requesting your employer cover the cost of this new product because it is medically necessary and not due to personal preference
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Review your letter for grammatical and spelling errors
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Conclude with action requested and timeframe for response
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Don’t get discouraged if you do not hear back right away
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Follow up after two weeks
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Be persistent without being pushy
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Be proud of yourself for taking action
*The National Drug Code Directory lists all over the counter and prescription products in the United States, including diabetes treatment technologies like Omnipod. The NDC number is a unique number that helps identify products in the United States, containing information about the manufacturer, the product, and the packaging. The Food and Drug Administration (FDA) publishes a regularly updated list of all NDC numbers.
A: Your employer’s human resources (HR) department should be able to address many of your insurance-related questions. If you want to see if your diabetes care is covered, need to file a claim, or are having trouble navigating your plan and understanding the costs, the HR department will support you.
A: It’s important to know the type of insurance you have because it impacts the total out-of-pocket expenses you will have. You will have expenses no matter what type of health insurance you have, but some plans are more affordable for diabetes care. These are the typical expenses you will encounter with your health insurance plan:
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Similar to paying rent, a premium is a fixed amount that you pay every month to keep your health insurance active2. It’s common for employers to pay about half of your monthly premium, and sometimes more. In 2019, people with employer-sponsored insurance paid an annual average of $1242 for health insurance premiums.
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Deductible -The deductible is the amount you pay out-of-pocket before your insurance provider covers expenses. For example, if you have a $1,000 deductible, your insurance coverage will not kick in until you’ve paid $1,000 in healthcare expenses for that year.
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Copays -Copays are a fixed amount that you pay for a health service or medication, and your insurance provider covers the rest of the cost. Copays are a helpful way to pay for diabetes care because they are fixed, predictable costs that people can plan for.
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Coinsurance -Unlike fixed-price copays, coinsurance costs are a percentage of the total price of a health service or medication. These expenses are less predictable because medication prices can fluctuate.
There are three main types of health insurance – health maintenance organizations (HMO), preferred provider organizations (PPO) and high deductible health plans (HDHP). Here is an overview of the different types of health plans and what they might cost:
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HMO -Health maintenance organizations have high premiums and low deductibles. An HMO plan covers healthcare within a network of hospitals and healthcare professionals. Your providers must be in network in order to get your diabetes care covered.If your diabetes care professionals are in-network, this is often the most cost-effective healthcare option for people with diabetes.
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PPO -Preferred provider organizations also have higher premiums and lower deductibles than HDHPs. PPOs are more flexible than HMOs because you are able to see providers out-of-network, and you can see specialists without a referral. Because of this, PPOs typically have higher premiums and out-of-pocket costs than HMO plans.
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HDHP -High deductible health plans typically have low monthly premiums and high deductibles. In 2020, the IRS defined a HDHP as any plan with a deductible of at least $1,400 for an individual and $2,800 for a family. If you have a high deductible health plan, you can open a health savings account whereyou set aside money to pay for medical expenses tax-free. These health plans are good for people who don’t anticipate needing regular healthcare; paying for diabetes care can be difficult with this type of plan because you will have high out-of-pocket costs upfront before you meet your deductible.
A: Robust employer-sponsored health insurance plans should make medical expenses related to diabetes affordable and predictable. If you are trying to make permanent changes to your employer-sponsored health plan, your HR department can help you advocate for future health plans that better support diabetes needs. Employers have the power to make changes to their health coverage options every year. Here are some changes you can advocate for:
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Add insulin and other diabetes care to the preventive medicine list
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Request to get a medication or device covered under your health plan
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Share discounts and rebates with employees
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Use copayments for cost sharing instead of unpredictable coinsurance
To familiarize yourself with how you can work with your employer for better coverage, read our article How to Advocate for Yourself: Making Employer-Sponsored Health Plans Work for Your Diabetes Care
To familiarize yourself with how you can work with your employer for better coverage, read our article How to Advocate for Yourself: Making Employer-Sponsored Health Plans Work for Your Diabetes Care
Learn How to Advocate for
the Coverage You Need
If your employer-sponsored health coverage does not provide the benefits you need to cover diabetes therapies like Omnipod, there are steps you can take to advocate for yourself. This short, informative video tells you everything you need to know to get started.
We're Here to Support You
Still unsure about how to engage with your employer for the insurance coverage needed
for diabetes therapy and technology? Our customer care team can help.
