CurrentCignaPolicy N/A

Diabetes - V-Go Products Drug Quantity Management Policy - Per Days

Defines drug quantity limits and allowance of one-time overrides for V-Go 20, 30, and 40 wearable insulin delivery devices for Cigna-administered health benefit plans.

Policy Summary

PayerCigna

PolicyDiabetes - V-Go Products Drug Quantity Management Policy - Per Days

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateMar 25, 2026

Key ActionApprove a one-time override for up to 30 V-Go devices at retail or home delivery when the prescriber documents the patient requires replacement of one or more devices.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

30maximum retail qty per 30 days

90maximum home delivery qty per 90 days

30one-time override qty

30package size

Coverage Criteria for V-Go Devices

Quantity Limits and One-time Override

Quantity limits apply to V-Go 20, 30, and 40 devices; exceptions covered as medically necessary when criteria met.

Drug quantity limits: Retail maximum quantity per 30 days = 30 devices for each V-Go 20, V-Go 30, and V-Go 40; Home delivery maximum quantity per 90 days = 90 devices for each V-Go 20, V-Go 30, and V-Go 40; package size = 30 devices per package.see values

Refer to Drug Quantity Limits.

Exceptions - one-time override: Approve a one-time override for 30 devices at retail or home delivery if the prescriber states the patient requires an additional quantity due to the need to replace one or more V-Go devices.30 devices

Approvals are provided for 1 year unless otherwise noted; one-time override permitted as described in criteria.

EXCEPTIONS TO THE QUANTITY LIMITS LISTED ABOVE ARE COVERED AS MEDICALLY NECESSARY WHEN THE FOLLOWING CRITERIA ARE MET. ANY OTHER EXCEPTION IS CONSIDERED NOT MEDICALLY NECESSARY.

Policy Summary

PayerCigna

PolicyDiabetes - V-Go Products Drug Quantity Management Policy - Per Days

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateMar 25, 2026

Key ActionApprove a one-time override for up to 30 V-Go devices at retail or home delivery when the prescriber documents the patient requires replacement of one or more devices.

SourceLink

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Provider Actions, Approval, and Denial Risk

Note

Approval duration and one-time override

This Drug Quantity Management program has been developed to promote the safe, effective, and economic use of V-Go Products. All approvals are provided for 1 year in duration unless otherwise noted. A one-time override is available for up to 30 devices and is provided for a duration of 30 days. If the Drug Quantity Management rule is not met for the requested medication at the point of service, coverage will be determined by the Criteria in this policy.

Approvals provided for 1 year unless noted
One-time override: up to 30 devices (retail or home delivery) for 30 days

Documentation Required

Documentation of applicable benefit plan and facts

Documentation of the applicable benefit plan and the specific facts of the case is required for coverage determinations. Coverage decisions must consider: 1) the terms of the applicable benefit plan document in effect on the date of service; 2) applicable laws and regulations; 3) relevant collateral materials including this coverage policy; and 4) the specific clinical facts presented. Providers should submit the applicable benefit plan information and supporting clinical documentation when requesting coverage or an exception.

Provide the applicable benefit plan document or reference (e.g., group service agreement, evidence of coverage) where available
Include clinical facts supporting medical necessity when requesting an exception to quantity limits

Denial Risk

Denial risk for exceeding quantity limits

If the Drug Quantity Management rule is not met at the point of service and the requested quantity exceeds the policy limits, the request may be denied. Providers should be aware of the specified retail and home delivery maximum quantities to avoid denials at point of sale.

Retail maximum: 30 devices per 30 days
Home delivery maximum: 90 devices per 90 days
Exceptions are covered as medically necessary only when criteria are met; other requests will be denied

Prior Authorization

Provider action: Approve a one-time override for 30 devices at retail or home delivery if, according to the prescriber, the patient requires an additional quantity due to the need to replace one or more V-Go devices.

One-time override: approve up to 30 devices (retail or home delivery) when replacement of one or more V-Go devices is required per prescriber

Background

The V-Go wearable insulin delivery device provides basal-bolus subcutaneous insulin delivery for adults who require insulin. Each V-Go device is single-use for 24 hours and is supplied in a package size of 30 devices. The V-Go models (20, 30, and 40) deliver differing basal insulin amounts over 24 hours and are compatible with U-100 rapid-acting insulins; approved products such as Humalog and NovoLog have been tested with V-Go.

For quantity management, each V-Go model has a retail maximum of 30 devices per 30 days and a home delivery maximum of 90 devices per 90 days. A one-time override for up to 30 devices at retail or home delivery may be approved when the prescriber documents the need to replace one or more V-Go devices.

OpenPayer

Diabetes - V-Go Products Drug Quantity Management Policy - Per Days

Coverage Criteria for V-Go Devices

Provider Actions, Approval, and Denial Risk

Definitions

Background