Omnipod 5 dexcom g7g6 int — Blue Cross Blue Shield of Illinois

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

Approval duration

12 months