Disposable insulin delivery systems (Omnipod DASH and Omnipod 5) — Prior authorization and coverage criteria
Customize your policy alerts
Sign up for all Georgia Department of Community Health policy alerts
Know when Georgia Department of Community Health releases new policies or updates existing guidance.
Monitor payer policy activity
Prior authorization and coverage criteria for Omnipod DASH and Omnipod 5 disposable insulin delivery systems for Georgia Medicaid Fee-For-Service members, including age, diagnosis, training, quantity limits, and QLL exceptions.
No material clinical or coverage changes in this revision.
Coverage and Medical Necessity Criteria
Omnipod 5 Initial Approval
Omnipod 5 is approvable when the following are met:
Member must be under the direct supervision of the prescriber
Omnipod DASH Initial Approval
Omnipod DASH is approvable when ALL of the following are met:
Prior authorization for Omnipod devices must be requested by the prescriber (pharmacists may not initiate PA requests). Coverage is limited to members aged 2 to 21 years. For both Omnipod 5 and Omnipod DASH, only one intro kit per 4 years will be covered.
Omnipod DASH requires documentation of inadequate control on multiple daily injections before approval. Specifically, the member must have a documented history of poor glycemic control on multiple daily injections — including a persistently elevated HbA1c > 7.0% — or documented cognitive impairment. Absent this documentation, use of Omnipod DASH does not meet the policy’s stated approval criteria.
Coding and Quantity Rules
| 08508-2000-32 | Omnipod DASH - Intro Kit (NDC) |
| 08508-2000-05 | Omnipod DASH - Pods (NDC) |
| 08508-3000-01 | Omnipod 5 - Intro Kits (NDC) |
| 08508-3000-88 | Omnipod 5 - Intro Kits (NDC) |
| 08508-3000-21 | Omnipod 5 - Pods (NDC) |
| 08508-3000-42 | Omnipod 5 - Pods (NDC) |
Prior Authorization, Documentation, and Prescriber Responsibilities
Prior authorization must be requested by the prescriber via OptumRx
Prior authorization is required for disposable insulin delivery systems and must be requested by the prescriber through the OptumRx prior authorization process.
- Prescriber-initiated PA only; pharmacists cannot request PA for Omnipod ([[chunk 2]]).
- PA requests and exceptions are handled via OptumRx (call 1-866-525-5827) ([[chunk 8]]).
- NDCs for devices are listed in the policy and require PA (e.g., Omnipod DASH and Omnipod 5 NDCs) ([[chunk 0]]).
Step requirement — document poor glycemic control on multiple daily injections (or cognitive impairment)
Omnipod DASH approval requires documentation that the member has a history of poor glycemic control on multiple daily injections (including persistently elevated HbA1c >7.0%) or evidence of cognitive impairment prior to approval.
- Documented history of poor glycemic control on multiple daily injections, including HbA1c >7.0%.
- Alternatively, documentation of cognitive impairment meeting the policy criteria.
Required documentation to support PA
Submit documentation that verifies the member's age and diabetes diagnosis, confirms the member is under direct supervision of the prescriber, and shows the member or caregiver has received appropriate device training; for Omnipod DASH include evidence of poor glycemic control (HbA1c >7.0%) or cognitive impairment when applicable.
- Age and diagnosis: 2–21 years for general approval; 18–21 years for Omnipod 5 with T2DM (as applicable) ([[chunk 4]], [[chunk 5]]).
- Prescriber direct supervision statement or documentation ([[chunk 4]], [[chunk 5]]).
- Documentation of training for member or caregiver on device use ([[chunk 4]], [[chunk 5]]).
- For Omnipod DASH, include HbA1c results >7.0% or other notes documenting cognitive impairment ([[chunk 5]]).
Prescriber-only PA requests; common denial triggers (age, diagnosis, kit frequency)
Only prescribers may initiate PA requests; requests from non-prescribers (e.g., pharmacists) will not meet the policy's PA initiation requirement and members outside the specified age/diagnosis limits risk denial.
- PA requests must be initiated by a prescriber — pharmacists cannot request PA for Omnipod ([[chunk 2]]).
- Coverage limited to specified ages and diagnoses (e.g., 2–21 years for general coverage; 18–21 years with T2DM for Omnipod 5); members outside these ranges may be denied ([[chunk 4]], [[chunk 5]]).
- Only one intro kit will be covered per 4 years; requests exceeding kit frequency may be denied ([[chunk 2]]).
Background
Disposable tubeless insulin delivery systems covered by this policy (Omnipod DASH and Omnipod 5) provide insulin delivery for members with diabetes mellitus and require device-specific training and prescriber oversight. The policy distinguishes eligibility by age and diagnosis, requires that the member (or caregiver) receive appropriate training on device use, and limits PA requests to those initiated by the prescriber. Intro kits are subject to a frequency limit of one kit every 4 years.
Definitions and Operational Notes
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.