Omnipod 5 libre2 plus g6 — Blue Cross Blue Shield of Illinois

diabetes mellitus requiring insulin therapy

Initial criteria

ONE of the following:
A. Patient has been using the requested product within the past 90 days AND is at risk if therapy is changed OR
B. Patient currently has an insulin pump (e.g. Omnipod Eros, Minimed, Guardian) but it is not functioning properly AND is past warranty OR
C. ALL of the following:
1. Patient has diabetes mellitus AND requires insulin therapy AND
2. BOTH of the following:
A. Patient is on an insulin regimen of 3 or more injections per day AND
B. Patient performs 4 or more blood glucose tests per day or is using Continuous Glucose Monitoring (CGM) AND
3. Patient has completed a comprehensive diabetes education program AND
4. Patient has demonstrated willingness and ability to play an active role in diabetes self-management AND
5. Patient has had ONE of the following while compliant on an optimized multiple daily insulin injection regimen:
A. HbA1C > 7% OR
B. History of recurring hypoglycemia OR
C. Wide fluctuations in blood glucose before mealtime OR
D. Dawn phenomenon with fasting blood sugars frequently > 200 mg/dL OR
E. History of severe glycemic excursions AND
2. ONE of the following:
A. Patient’s age is within manufacturer recommendations for the requested indication for the requested product OR
B. There is support for using the requested product for the patient’s age

12 months