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

Diabetes mellitus (patients requiring insulin therapy)

Initial criteria

  • Request is for Omnipod (e.g., Omnipod DASH, Omnipod 5), Twiist or V-Go AND ONE of the following criteria are met:
  • 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 is using a continuous glucose monitor (CGM).
  • • If patient does NOT have type 1 diabetes, then the patient has had elevated HbA1c >7% while on multiple daily injections (≥3 injections/day) for at least 6 months OR has had ANY of: recurrent hypoglycemia (blood glucose <70 mg/dL), wide pre-meal glucose fluctuations, dawn phenomenon with fasting glucose >200 mg/dL, or severe glycemic excursions.
  • • If an Omnipod starter kit is requested, patient has not received an Omnipod starter kit within the past 2 years.
  • • If a Twiist starter kit is requested, patient has not received a Twiist starter kit within the past 2 years.
  • • If additional quantities of Omnipod pods are 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 are 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 CGM.
  • • If an Omnipod starter kit is requested, patient has not received an Omnipod starter kit within past 2 years.
  • • If a Twiist starter kit is requested, patient has not received a Twiist starter kit within past 2 years.
  • • If additional quantities of Omnipod pods are 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 are requested, patient requires >300 units of insulin within a 72-hour period.

Approval duration

12 months