Ilet insulin infusion kit — Blue Cross Blue Shield of Illinois

patients residing in Ohio whose plan is Fully Insured or HIM Shop

Initial criteria

1. The member resides in Ohio AND
2. The plan is Fully Insured or HIM Shop (SG) AND BOTH of the following:
A. Patient does NOT have any FDA labeled contraindications to the requested agent AND
B. ONE of the following:
1. Patient has another FDA labeled indication for the requested agent and route of administration OR
2. Patient has another indication supported in compendia for the requested agent and route of administration OR
3. Prescriber has submitted TWO articles from major peer-reviewed professional medical journals (e.g. JAMA, NEJM, Lancet) supporting the proposed use(s) as generally safe and effective

12 months