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V-Go (all products) — CareFirst (Caremark)

Diabetes mellitus

Initial criteria

  • Request is for Omnipod products (e.g., Omnipod DASH, Omnipod 5), Twiist, or V-Go AND ONE of the following:
  • Patient is NOT currently established on therapy with an insulin pump AND ALL of the following:
  • Patient is managing diabetes with multiple daily insulin injections.
  • Patient has completed a comprehensive diabetes education program.
  • Patient has documented frequency of glucose self-testing an average of at least 4 times per day OR patient is using a continuous glucose monitor (CGM).
  • If patient does NOT have a diagnosis of type 1 diabetes, then patient has experienced elevated glycosylated hemoglobin level (HbA1c > 7%) while on multiple daily injections (≥3 injections per day) for ≥6 months OR has experienced ANY of: recurrent hypoglycemia (blood glucose <70 mg/dL), wide fluctuations in blood glucose before mealtime, “dawn” phenomenon with fasting blood sugars >200 mg/dL, or history of severe glycemic excursions.
  • If Omnipod starter kit requested, patient has not received Omnipod starter kit within past 2 years.
  • If Twiist starter kit requested, patient has not received Twiist starter kit within past 2 years.
  • If additional quantities of Omnipod pods requested, patient requires >200 units of insulin within a 72-hour period.
  • If additional quantities of Twiist Refill Kits or Refill Kits with Infusion Sets requested, patient requires >300 units of insulin within a 72-hour period.
  • OR patient is currently established on therapy with an insulin pump AND ALL of the following:
  • Patient has documented frequency of glucose self-testing an average of at least 4 times per day OR is using a continuous glucose monitor (CGM).
  • If Omnipod starter kit requested, patient has not received Omnipod starter kit within past 2 years.
  • If Twiist starter kit requested, patient has not received Twiist starter kit within past 2 years.
  • If additional quantities of Omnipod pods requested, patient requires >200 units of insulin within a 72-hour period.
  • If additional quantities of Twiist Refill Kits or Refill Kits with Infusion Sets requested, patient requires >300 units of insulin within a 72-hour period.

Approval duration

12 months