Twiist starter kit — Blue Cross Blue Shield of Texas

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

The requested agent will also be approved when ALL of the following are met:
1. The member resides in Ohio AND
2. The plan is Fully Insured or HIM Shop (SG) AND BOTH of the following:
A. The patient does NOT have any FDA labeled contraindications to the requested agent AND
B. 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 (case studies not acceptable)

12 months