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)
P & T Revisions
2024-06-05, 2023-05-25, 2022-06-17, 2021-08-31, 2021-05-19, 2021-05-19
References
Revision History
- 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
HEALTHY LIVING