Omnipod dash pdm kit (gen — Blue Cross Blue Shield of Montana

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) that 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 injections per day AND
• B. Patient performs ≥4 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 ONE of the following while compliant on 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 age is within manufacturer recommendations for the requested indication OR
• B. There is support for use for the patient’s age
• For members residing in Ohio, fully insured or HIM Shop (SG) plans require:
• 1. Patient does not have any FDA labeled contraindications to the requested agent AND
• 2. ONE of the following:
• A. Patient has another FDA labeled indication for the requested agent and route of administration OR
• B. Patient has another indication supported in compendia OR
• C. Prescriber has submitted two peer-reviewed medical journal articles supporting the proposed use

Reauthorization criteria

• Same clinical criteria as initial approval may apply at renewal to confirm continued clinical appropriateness

Approval duration

12 months