CurrentBlue Cross Blue Shield - South CarolinaPolicy N/A

Omnipod prior authorization request for insulin pump therapy

A payer-specific prior authorization form and requirements for coverage of the Omnipod insulin pump system, describing information providers must submit and clinical criteria used to evaluate requests for members.

Policy Summary

PayerBlue Cross Blue Shield - South Carolina

PolicyOmnipod prior authorization request for insulin pump therapy

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit the completed two-page Omnipod Prior Authorization Request Form (fax 844-403-1029 or via OptumRx/CoverMyMeds) with required clinical checklist items.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2form length

7required checklist items

≥4x/dayself-testing frequency

≥6 moMDI duration

Coverage and Medical Necessity Criteria

Initial prior authorization criteria

Covered when ALL of the following are documented on the form

Primary criteria: 1) Diagnosis of diabetes; 2) Completion of comprehensive diabetic education; 3) Program of multiple daily injections (at least 3 injections per day) with frequent self-adjustments of insulin dose for at least 6 months prior to initiation of the insulin pump; 4) Documented average frequency of glucose self-testing of at least 4 times per day during the 2 months prior to initiation of the insulin pump; 5) Evidence of failure of intensive treatment as demonstrated by one or more of the following: dawn phenomenon with fasting blood sugars frequently exceeding 200 mg/dL; hemoglobin A1C greater than 7.0%; history of severe glycemic excursions; history of severe hypoglycemia or ketoacidosis; multiple insulin injections per day (3 or more); multiple physician office visits; wide pre-prandial glucose fluctuations (e.g., pre-prandial blood glucose commonly exceeds 140 mg/dL); 6) If the patient was previously on a pump prior to enrollment with the current plan, documented average glucose self-testing of at least 4 times per day during the month prior to enrollment; 7) If requesting Omnipod for pre-conception or pregnancy, documentation that the request is to reduce the incidence of fetal mortality or anomaly.see individual nodes

Form lists these as required checklist items

The Omnipod prior authorization form does not list any explicit exclusions; coverage is determined by affirmative documentation of required clinical items. Approval is contingent on completion of the checklist items on the form, which request confirmation of a diabetes diagnosis, completion of comprehensive diabetic education, prior intensive insulin management (including a program of multiple daily injections), documented frequency of glucose self‑testing, evidence of failure of intensive treatment (specific findings listed on the form), prior pump use when applicable, and pregnancy/pre‑conception indication when relevant.

Policy Summary

PayerBlue Cross Blue Shield - South Carolina

PolicyOmnipod prior authorization request for insulin pump therapy

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit the completed two-page Omnipod Prior Authorization Request Form (fax 844-403-1029 or via OptumRx/CoverMyMeds) with required clinical checklist items.

SourceLink

On This Page

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Key Coding & Definition Highlights

inv-04: Glucose self-testing frequency — average of at least 4 times per day

Required average frequencyDocumented average of at least 4 times per day (during the 2 months prior to pump initiation)

Measurement periodAverage calculated over the 2 months prior to initiation of the insulin pump

Evidence sourceSelf-monitoring logs or documented testing records submitted on the Omnipod Prior Authorization Request Form

inv-05: Duration on multiple daily injections — at least 6 months prior to initiation of the insulin pump

Required durationOn a program of multiple daily injections with frequent self-adjustments for at least 6 months prior to initiation of the insulin pump

Minimum injections/dayProgram defined as at least 3 injections per day (see multiple daily injections definition)

DocumentationProvider must indicate this duration on the Omnipod Prior Authorization Request Form clinical checklist

What the Provider Must Do

Prior Authorization

Form-based prior authorization required

Omnipod Prior Authorization Request Form (two-page) must be completed and submitted. The form may be faxed to 844-403-1029 or submitted via CoverMyMeds (go.covermymeds.com/OptumRx) per OptumRx partnership. For assistance with the prior authorization process, contact 855-811-2218.

Fax: 844-403-1029
CoverMyMeds: go.covermymeds.com/OptumRx
Prior authorization help: 855-811-2218

Documentation Required

Required submission contents — complete two-page form

The two-page Omnipod Prior Authorization Request Form must include complete provider and member demographics plus clinical information. Required fields include provider name, NPI, specialty, office phone/fax/address, member name, insurance ID, date of birth, and medication details (name, strength, dosage form, directions).

Provider/member demographics: provider name, NPI, specialty, office phone, office fax, office address, member name, insurance ID#, date of birth
Medication information: medication name, strength, dosage form, directions for use
Complete clinical sections on page 2 where applicable

Documentation Required

Prior intensive treatment documentation required

Document prior intensive insulin management. The form requires documentation that the patient has been on a program of multiple daily injections (≥3 injections/day) with frequent self-adjustments for at least 6 months prior to pump initiation, frequency of glucose self-testing (average ≥4 times/day during the 2 months prior), and evidence that intensive treatment failed to control blood sugars (examples listed on the form). Include dates, duration, and relevant lab values or notes.

Multiple daily injections: at least 3 injections per day for ≥6 months prior to pump initiation
Glucose self-testing: average ≥4 times/day during the 2 months prior to initiation (or month prior for prior-pump enrollment)
Evidence of failed intensive treatment: A1C >7.0%, dawn phenomenon with fasting BG frequently >200 mg/dL, severe glycemic excursions, severe hypoglycemia or ketoacidosis, wide pre‑prandial fluctuations, multiple physician visits

Denial Risk

Incomplete submission risk

Incomplete submissions risk denial. This request may be denied unless all required information on the two-page form is received. Ensure all fields and supporting clinical documentation are provided before submission.

Incomplete forms or missing clinical documentation may result in denial
Office hours: Mon–Fri 8 a.m.–1 a.m. ET; Sat 9 a.m.–6 p.m. ET

OpenPayer

Omnipod prior authorization request for insulin pump therapy

Coverage and Medical Necessity Criteria

Key Coding & Definition Highlights

What the Provider Must Do

Clinical Background

Definitions and Thresholds