WHA

Insulin Delivery Systems

Indications for Prior Authorization

Criteria

Insulin dosers, cartridges, or pen devices

Administrative

  • Will be approved, except when excluded as a plan benefit, based on one of the following criteria:
    • The patient has visual impairment (unable to use insulin vial and syringe)
      • OR
    • The patient has physical impairment (unable to use insulin vial and syringe)

  • Guideline ID
    GL-147237

  • Formulary
    EHB

  • Effective date
    Aug 1, 2024

  • P&T approval date
    Jun 23, 2009

P & T Revisions

2024-06-05, 2023-05-25, 2022-06-17, 2021-08-31, 2021-05-19, 2021-05-19

  • 2024-06-05: 2024 Annual Review - no changes
  • 2023-05-25: 2023 Annual Review
  • 2022-06-17: Annual review: no criteria changes. Added "cartridge" as a search term.
  • 2021-08-31: 2021 Annual Review
  • 2021-05-19: Addition of EHB formulary to guideline, no changes to criteria. update note
  • 2021-05-19: Addition of EHB formulary to guideline, no changes to criteria

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