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Ilet starter kit - contac — Blue Cross Blue Shield of Oklahoma

diabetes mellitus requiring insulin therapy

Initial criteria

  • Target Agent(s) will be approved when BOTH of the following are met:
  • 1. ONE of the following:
  • A. The patient has been using the requested product within the past 90 days AND is at risk if therapy is changed OR
  • B. The 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. The patient has diabetes mellitus AND requires insulin therapy AND
  • 2. BOTH of the following:
  • A. The patient is on an insulin regimen of 3 or more injections per day AND
  • B. The patient performs 4 or more blood glucose tests per day or is using Continuous Glucose Monitoring (CGM) AND
  • 3. The patient has completed a comprehensive diabetes education program AND
  • 4. The patient has demonstrated willingness and ability to play an active role in diabetes self-management AND
  • 5. The patient has had ONE of the following while compliant on an optimized multiple daily insulin injection regimen:
  • A. Glycosylated hemoglobin level (HbA1C) greater than 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 exceeding 200 mg/dL OR
  • E. History of severe glycemic excursions AND
  • 2. 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

Reauthorization criteria

  • The requested agent will be approved when all initial criteria continue to be met and clinical benefit is maintained.
  • The patient does not have any FDA labeled contraindications to the requested agent.
  • ONE of the following:
  • 1. The patient has another FDA labeled indication for the requested agent and route of administration OR
  • 2. The patient has another indication that is supported in compendia for the requested agent and route of administration OR
  • 3. The prescriber has submitted TWO articles from major peer-reviewed professional medical journals supporting the proposed use(s) as generally safe and effective.

Approval duration

12 months