Omnipod dash pdm kit (gen 4) — Blue Cross Blue Shield of Kansas

Initial criteria

• ONE of the following: A. The patient has been using the requested product within the past 90 days OR B. The prescriber states the patient has been using the requested product within the past 90 days AND is at risk if therapy is changed OR C. ALL of the following: 1. The patient has diabetes mellitus AND requires insulin therapy AND 2. The patient is on an insulin regimen of 3 or more injections per day AND 3. The patient performs 4 or more blood glucose tests per day or is using Continuous Glucose Monitoring (CGM) AND 4. The patient has completed a comprehensive diabetes education program AND 5. The patient has demonstrated willingness and ability to play an active role in diabetes self-management AND 6. The 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 ONE of the following: A. The patient’s age is within the 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.

Approval duration

12 months