Pharmacy Prior Authorization Criteria

Insulin Pump

Indications for Prior Authorization

Omnipod 5 G6 and Omnipod 5 DASH:

• For diagnosis of Diabetes mellitus (DM)
  Indicated for individuals with diabetes mellitus who require multiple daily injections of insulin can use external insulin pumps to administer insulin through continuous subcutaneous infusion. To be covered, members must meet specific coverage criteria.

Criteria

Omnipod

Prior Authorization (Initial Authorization)

Length of Approval: 1 Year(s)
For diagnosis of Diabetes Mellitus (DM)

• Diagnosis of diabetes (i.e., type I, type II, LADA) that requires multiple daily injections of insulin (i.e., three or more daily)
AND
• Prescribed by or in consultation with a diabetes educator or endocrinologist.
AND
• ONE of the following:
• Prescriber attests to one of the following:
• Patient completed a diabetes education program within the preceding 24 months.
• Patient (or someone assisting the individual) is capable of managing the pump and adjusting insulin doses as needed.
• Patient has used at least three injections of insulin per day involving self-adjustments of insulin dosage for at least six months.
OR
• For continuation of Omnipod therapy, defined as no more than a 45-day gap in therapy
AND
• The number of pods prescribed over time corresponds to the estimated total daily insulin usage (max of 15 pods per month).

Omnipod

Prior Authorization (Reauthorization)

Length of Approval: 1 Year(s)
For diagnosis of Diabetes Mellitus (DM)

• Documentation of positive clinical response.

P & T Revisions

1970-01-01, 2024-11-04

References

1. Provider Resources | OmniPod HCP. https://www.omnipod.com/hcp/clinical-resources/provider-resources

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Revision History

• 2024-11-04: New Program

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