CurrentCignaPolicy CNF981

Diabetes – CeQur Products Drug Quantity Management Policy – Per Days - (CNF981)

Defines quantity limits and medically necessary exception criteria for CeQur Simplicity 4-Day Insulin Patch and CeQur Simplicity Inserter for Cigna-administered health benefit plans, including retail and home delivery maximums and one-time override rules.

Policy Summary

PayerCigna

PolicyDiabetes – CeQur Products Drug Quantity Management Policy – Per Days - (CNF981)

Policy CodePolicy CNF981

Change TypeNew policy

Effective Date

Next Review Date

Key ActionIf the Drug Quantity Management rule is not met at point of service, coverage will be determined by the listed criteria; approvals are provided for 1 year unless otherwise noted; one-time overrides provide a 30-day duration.

SourceLink

POLICY UPDATE CHANGES

New policy created for Drug Quantity Management of CeQur products.

8Retail maximum per 30 days (patches)

24Home delivery per 90 days (patches)

1Inserter max per 720 days

1 yrStandard approval duration

30 daysOne-time override duration

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Coverage Summary

Quantity thresholds and headline metrics (CeQur Simplicity Patch & Inserter)

Quantity Limit Exceptions — CeQur Simplicity 4‑Day Insulin Patch

Quantity Limit Exceptions - CeQur Simplicity 4-Day Insulin Patch

Exceptions to quantity limits are covered as medically necessary when ALL of the following are met:

Patch change frequency: If a patient requires the patch to be changed more frequently than every 4 days, approve the requested quantity for a 30-day supply at retail and a 90-day supply at home delivery.Retail: 8 patches/30 days; Home delivery: 24 patches/90 days
Approvals provided for 1 year unless otherwise noted; one-time overrides are 30 days per policy guidance.
Emergency Kit extra patch: If a patient requires an extra patch to carry in their Emergency Kit, approve a one-time override for 8 patches (one carton).One-time override = 8 patches
User Guide recommends carrying an Emergency Kit including at least one new, sealed patch.

Quantity Limit Exceptions — CeQur Simplicity Inserter

Quantity Limit Exceptions - CeQur Simplicity Inserter

Exceptions to quantity limits are covered as medically necessary when ANY of the following are met:

Lost inserter: Patient's inserter device has been lost.
Approvals for inserter are one-time overrides.
Damaged inserter: Patient's inserter device has been damaged.
Approvals for inserter are one-time overrides.
Malfunctioning inserter: Patient's inserter device is not functioning properly.
Approvals for inserter are one-time overrides.

Applicable Codes / Products

Products referenced (no billing codes specified)mixed

CeQur Simplicity 4-Day Insulin Patch	4-day insulin patch; package size = 8 patches per carton; each patch single-use; filled 100-200 units; changes every 4 days
CeQur Simplicity Inserter	Single-use inserter device; supplied in single-inserter packages

Provider Actions

Prior Authorization

Quantity management rule and approval duration

If the Drug Quantity Management rule is not met at point of service, coverage will be determined by the listed criteria. All approvals are provided for 1 year in duration unless otherwise noted. One-time overrides provide a 30-day duration.

Documentation Required

Documentation to support inserter one-time override

Document loss, damage, malfunction, or clinical need for a second inserter (for example, to carry in an Emergency Kit). Approval quantity should be based on the number of CeQur inserters the patient has received in the past 720 days plus one inserter. Approvals for inserter one-time overrides are provided as a one-time 30-day override.

Clinical Evidence & Background

The CeQur Simplicity On-Demand Insulin Delivery System is a patch-based, on‑demand bolus insulin delivery system intended for adults requiring insulin. The system includes a patch, an inserter, a fill syringe, and a dose count card. Only Humalog (insulin lispro 100 units/mL) and NovoLog (insulin aspart 100 units/mL) have been tested for use. Each patch is single-use, delivers insulin in 2-unit clicks, must be filled with a minimum of 100 units and a maximum of 200 units, and must be changed at least every 4 days.

Manufacturer user guide reference — CeQur Simplicty 4-Day Insulin Patch user guide; 2025

Definition: Emergency Kit

Revision History

2026-03-25Policy created / New policyLatest

New Policy created for Drug Quantity Management of CeQur products. History notes: New Policy, Review Date = 03/25/2026.