Insulin Pump Therapy (Omnipod DASH, Omnipod 5)

Insulin Pump Therapy (Omnipod DASH, Omnipod 5)

Diagnosis considered for coverage:

Diabetes mellitus (DM): 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.

Coverage Criteria:

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.
  • 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.

Reauthorization Criteria:

For diagnosis of DM:

• Documentation of positive clinical response.

Dosing:

• The Omnipod 5 G6 Intro Kit includes the controller and 10 Pods that requires change every 48 to 72 based on total daily insulin usage.
• The Omnipod 5 G6 Pods (Gen 5) Refill 5-Pack includes the 5 Pods per box. Two boxes (i.e., 10 Pods total) are required to provide up to a 30-day supply.
• The Omnipod 5 DASH Intro Kit includes the controller and 10 Pods that requires change every 48 to 72 based on total daily insulin usage.
• The Omnipod 5 DASH Pods (Gen 4) Refill 5-Pack includes the 5 Pods per box. Two boxes (i.e., 10 Pods total) are required to provide up to a 30-day supply.

Coverage Duration:

• One year

Authorization is not covered for the following:

The use of this product for indications not listed in this policy does not meet the coverage criteria established by the Western Health Advantage (WHA) Pharmacy and Therapeutics (P&T) Committee.

Additional Information:

• Omnipod 5 is supplied as a tubeless, wearable and waterproof Pod that sits on body for up to 3 days (72 hours). The Omnipod 5 with built in SmartAdjust™ technology works with the Dexcom G6 continuous glucose monitor (CGM) to automatically adjust insulin delivery. The Omnipod 5 Pod is controlled by the Omnipod 5 App on compatible smartphones or through a free Personal Diabetes Manager (PDM) Controller provided with the Intro Kit.
• Omnipod DASH is supplied as a tubeless, wearable and waterproof Pod that sits on body for up to 3 days (72 hours). The Omnipod DASH is not compatible with CGMs and will not automatically adjusts insulin delivery. The Omnipod DASH Pod is controlled by the free PDM Controller provided with the Intro Kit. It is not compatible with smartphones.
• Different Pod generations are not cross-compatible between the systems (e.g., the Omnipod DASH PDM Controller is not compatible with Omnipod 5 Pods).
• Omnipod is not a CGM.
• The Omnipod Classic products (i.e., generation 3 and earlier) are available as a durable medical equipment (DME) products, which may be covered under the medical benefit.

Policy Updates:

• 03/01/2023 – New utilization management policy approved by P&T (2/15/23).

References: