CurrentUnitedHealthcarePolicy BIP042.N

Diabetic Management, Services and Supplies

Defines UnitedHealthcare coverage, required provider actions, and benefits for diabetes management, supplies, education, and insulin-related services for covered members in applicable markets (includes California-specific statutory requirements).

Policy Summary

PayerUnitedHealthcare

PolicyDiabetic Management, Services and Supplies

Policy CodePolicy BIP042.N

Change TypeRevised statutory language and clarified payment wording for external infusion pump drugs

Effective DateApr 1, 2026

Next Review Date

Key ActionObtain prior authorization and meet medical necessity criteria for continuous subcutaneous insulin infusion pumps and related supplies; ensure physician orders and required certifications are documented.

SourceLink

POLICY UPDATE CHANGES

Revised language pertaining to California Health and Safety Code (HSC) Section 1367.51.

Replaced prior payment wording for drugs required for operation of external infusion pumps with clarified wording.

HSC §1367.51CA statute included

CoveredDSMT/ODSMT

Covered w/criteriaCSII pumps

$35 cap

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Coverage Criteria

Covered Benefits with Medical Necessity

Covered when ALL of the following are met:

General: Services and supplies are medically necessary and prescribed/ordered by a physician or participating provider; coverage is subject to the member's Evidence of Coverage/Schedule of Benefits and applicable federal/state mandated regulations and plan enhancements.

See Instructions for Use.

Outpatient diabetic self-management training (ODSMT/DSMT): Outpatient diabetic self-management training (ODSMT) and diabetic self-management training (DSMT), including initial training and additional visits when a physician identifies a significant change in the member's symptoms or condition, and medical nutrition therapy when ordered/prescribed and provided by appropriately licensed or registered health care professionals under the direction of a network provider; coverage follows Medicare Benefit Policy Manual, Chapter 15, §300 when applicable.

Physician must order/prescribe; training intended to educate self-monitoring, diet/exercise, and insulin treatment planning for insulin-dependent members.

Diabetic supplies and equipment: FDA‑approved diabetic supplies and equipment (including intermittent blood glucose monitors, testing strips, lancets/lancet devices, urine and ketone test strips, and insulin syringes) when prescribed/ordered by a physician based on medical need; physician must determine that the member or home support can be trained to use and monitor the equipment.

Modified blood glucose monitors and supplies for the visually impaired are covered under DME when physician certifies severe visual impairment (e.g., voice synthesizers, automatic timers, specially designed supplies).

Continuous subcutaneous insulin infusion (CSII) pumps and related supplies: Continuous subcutaneous insulin infusion pumps (CSII) and all related necessary supplies are covered when medical criteria are met; materials not available over‑the‑counter (for example, tubing, syringe reservoirs, special needles) are included; payment may be provided for drugs required for effective operation of an external infusion pump when reasonable and necessary.

Refer to the Medical Policy 'Continuous Glucose Monitoring and Insulin Delivery for Managing Diabetes' for detailed coverage criteria and any authorization requirements.

Not covered: Alcohol; alcohol wipes; betadine, betadine wipes, iodine, or iodine wipes; cotton swabs; peroxide; Phisohex; eyeglasses or contact lenses; implantable infusion pumps used for the infusion of insulin; insulin, except when the member has a supplemental prescription drug benefit or when insulin is used in conjunction with a continuous subcutaneous insulin infusion pump (CSII).

Implantable insulin infusion pumps are explicitly not covered.

Coding and Cost-Sharing

Coding — general notemixed

not specified

No explicit CPT/HCPCS/ICD-10/NDC codes listed in policy document.

Insulin cost-sharing cap — statutory details

Cost-sharing cap$35 for a 30-day supply

Applicable contractsLarge group, individual, and small group plans per state statute (with specific phase-in dates)

Tiering rulesIf plan uses tiers, cap applies to insulin drugs in Tier 1 and Tier 2; at least one insulin per drug type must be on Tier 1 or Tier 2

High-deductible plansHigh deductible health plans must not impose deductible/coinsurance > $35 for a 30-day insulin supply unless conflict with federal HDHP rules

Effective/phase-in datesStatute provisions include phased applicability (references include January 1, 2027 for individual/small group tier rules)

Provider Actions and Authorization

Prior Authorization

Prior Authorization Required for CSII and Related Supplies

Prior authorization is required for Continuous Subcutaneous Insulin Infusion (CSII) pumps and related supplies when medical necessity criteria are not clearly met in the member's Evidence of Coverage/Schedule of Benefits. Providers must ensure documentation of medical necessity is submitted with the prior authorization request.

Covered: CSII pumps and related supplies when medical criteria are met
Include documentation: physician order, training plan, and justification for pump vs other therapy
Payment may include drugs required for pump operation if reasonable and necessary

Step Therapy

Step Therapy Limitation for Insulin (Statutory)

Step therapy protocols must not be imposed as a prerequisite for coverage of insulin prescription drugs on or after January 1, 2026, except as allowed when at least one insulin in each drug type is covered without step therapy. Do not require members to try or fail other non-insulin drugs before authorizing insulin.

Definitions

Definition — Insulin prescription drug

DefinitionAn 'Insulin prescription drug' is a prescription drug that contains insulin and is used to control blood glucose levels to treat diabetes.

ScopeIncludes prescription insulin products regardless of administration route when used to treat diabetes.

Relation to coverage rulesSubject to statutory protections (e.g., step therapy prohibitions and cost-sharing limits) as described in the policy.

Definition — Drug type

Included typesRapid acting, regular (short) acting, intermediate acting, long acting, ultra-long acting, and premixed.

Interpretation'Drug type' is inclusive (not limited to listed examples) per statute.

Background

Diabetes management includes self-monitoring of blood glucose (SMBG), education about diet and exercise, medical nutrition therapy, and individualized insulin treatment plans for insulin-dependent patients. These services and supplies—such as intermittent blood glucose monitors, test strips, lancets, modified monitors for visually impaired members, and outpatient diabetic self-management training (ODSMT/DSMT)—are covered when medically necessary and when ordered or prescribed by a physician and provided by appropriately licensed or registered health care professionals. Continuous subcutaneous insulin infusion (CSII) pumps and their necessary supplies are covered when medical criteria are met; however, implantable insulin infusion pumps are not covered. The member's Evidence of Coverage/Schedule of Benefits governs specific limits and conditions for these benefits.