CurrentCignaPolicy N/A

Diabetes - Omnipod Pods Drug Quantity Management Policy - Per Days

Defines quantity limits and drug quantity management rules for Omnipod pods (multiple Omnipod pod types) for Cigna-administered health benefit plans and describes clinical override criteria where applicable.

Policy Summary

PayerCigna

PolicyDiabetes - Omnipod Pods Drug Quantity Management Policy - Per Days

Policy CodePolicy N/A

Change TypeQuantity limits added / annual revision

Effective DateN/A

Next Review DateN/A

Key ActionWhen submitting requests, follow the Drug Quantity Management rules at point of service and document any clinical override criteria to support quantities beyond standard limits.

SourceLink

POLICY UPDATE CHANGES

New quantity limits for Omnipod GO pods were added to policy.

New quantity limits of 15 pods per 30 days (retail) and 45 pods per 90 days (home delivery) were added for Omnipod 5 G6-G7 pods.

New quantity limits of 15 pods per 30 days (retail) and 45 pods per 90 days (home delivery) were added for Omnipod 5 G6-Libre 2 Plus pods.

15/30dRetail max (most pods)

45/90dHome delivery max (most pods)

72h / 200uReplacement interval / cap

85u min / 200u maxPod fill min/max

10–40 u/dayOmnipod GO basal rates

Coverage Criteria and Quantity Limits

Standard Drug Quantity Limits

Covered as medically necessary when quantity limits and criteria below are met. Any other exception is considered not medically necessary.

Standard quantity limits: Omnipod Classic, Omnipod DASH, and Omnipod 5 Pods (G6, G6-G7, G6-Libre 2 Plus): retail maximum 15 pods per 30 days; home delivery maximum 45 pods per 90 days. Omnipod GO Pods (discontinued): retail maximum 10 pods per 30 days; home delivery maximum 30 pods per 90 days.

Pods typically packaged as 5-pack (GO listed as 5 pods/pack or 10 units/day etc. per product listings).

Clinical Overrides

Clinical override criteria

More frequent pod changes: If a patient requires the pod to be changed more frequently than every 48 hours, approve the requested quantity for a 30-day supply at retail and a 90-day supply at home delivery.pod change interval < 48 hours

Policy Summary

PayerCigna

PolicyDiabetes - Omnipod Pods Drug Quantity Management Policy - Per Days

Policy CodePolicy N/A

Change TypeQuantity limits added / annual revision

Effective DateN/A

Next Review DateN/A

Key ActionWhen submitting requests, follow the Drug Quantity Management rules at point of service and document any clinical override criteria to support quantities beyond standard limits.

SourceLink

On This Page

Coding, Replacement Intervals, and Pod Capacity

Drug quantity entries (no billing codes listed)mixed

No codes listed

inv-06: Pod replacement interval

Pod replacement intervalPods should be replaced at least once every 72 hours or after delivering 200 units of U-100 insulin

Whichever comes firstReplace at 72 hours OR after 200 units delivered, whichever occurs first

Reason for earlier replacementPods may need replacement sooner for device issues or specific insulin type compatibility

inv-07: Apidra compatibility interval

Apidra compatibility intervalApidra (insulin glulisine) is compatible for use up to 48 hours

Other rapid-acting insulinsNovoLog, Fiasp, Humalog, Lyumjev, and Admelog are compatible for up to 72 hours

ApplicabilityApplies to Omnipod and Omnipod DASH systems per dosing guidance

inv-08: Pod insulin minimum and maximum

Minimum fill to start podEach pod requires a minimum of 85 units of U-100 insulin to begin operation

Maximum capacityEach pod can hold up to 200 units of U-100 insulin

Replacement triggerPod replacement may occur after delivering the maximum 200 units if reached before 72 hours

Provider Actions, Approvals, and Quantity Management

Note

Drug Quantity Management rule and overrides

This Drug Quantity Management program has been developed to promote the safe, effective, and economic use of Omnipod Pods. If the Drug Quantity Management rule is not met for the requested medication at the point of service, coverage will be determined by the stated criteria. All approvals are provided for 1 year in duration.

Documentation Required

Provider action highlight

Provider action: Submit documentation supporting the need for increased pod change frequency if requesting quantities that exceed standard 48-hour pod change limits.

Prior Authorization

Approval duration

Omnipod Classic Pods, Omnipod DASH Pods, Omnipod 5 Pods (G6, G6-G7, and G6Libre 2 Plus): If a patient requires the pod to be changed more frequently than every 48 hours, approve the requested quantity for a 30-day supply at retail and a 90-day supply at home delivery. Omnipod GO Pods: No overrides recommended.

Denial Risk

Quantity management noncompliance

If the Drug Quantity Management rule is not met for the requested medication at the point of service, coverage will be determined by the above criteria (approvals provided for 1 year).

Background

Omnipod systems are single-use, subcutaneous insulin delivery pods designed to provide both basal and bolus insulin delivery for patients with diabetes. The policy distinguishes multiple Omnipod pod families (Omnipod Classic, DASH, Omnipod 5, and Omnipod GO) and sets specific drug quantity limits and replacement guidance for each. Clinical override criteria permit more frequent pod changes for select pod types (e.g., when changes are needed more often than every 48 hours), but Omnipod GO pods are explicitly listed as having no overrides recommended. Standard quantity limits for most Omnipod pods are expressed as maximums per 30-day retail and 90-day home delivery supplies.

Definitions and Device Specifications

inv-14: Pod replacement interval

Replacement frequency rulePods should be replaced at least once every 72 hours or after delivering 200 units of U-100 insulin, whichever comes first

Exceptions for insulin typeSome insulin types (e.g., Apidra) require replacement sooner — Apidra compatible up to 48 hours

Device or pod issuesPods may need to be replaced more frequently due to pod or device issues

inv-15: Pod capacity and minimum fill

Minimum insulin to operateEach pod requires a minimum of 85 units of U-100 insulin to begin operation

Maximum insulin capacityEach pod can hold up to 200 units of U-100 insulin

Packaging notePods are available in packages of 5 pods each