![]() The Omnipod 5 with built in SmartAdjust™ technology works with the Dexcom G6 continuous glucose monitor (CGM) to automatically adjust insulin delivery. Omnipod 5 is supplied as a tubeless, wearable and waterproof Pod that sits on body for up to 3 days (72 hours).The use of this product for indications not listed in this policy does not meet the coverage criteria established by the Western Health Advantage (WHA) Pharmacy and Therapeutics (P&T) Committee. Two boxes (i.e., 10 Pods total) are required to provide up to a 30-day supply.Īuthorization is not covered for the following: The Omnipod 5 DASH Pods (Gen 4) Refill 5-Pack includes the 5 Pods per box.The Omnipod 5 DASH Intro Kit includes the controller and 10 Pods that requires change every 48 to 72 based on total daily insulin usage.Two boxes (i.e., 10 Pods total) are required to provide up to a 30-day supply. The Omnipod 5 G6 Pods (Gen 5) Refill 5-Pack includes the 5 Pods per box.The Omnipod 5 G6 Intro Kit includes the controller and 10 Pods that requires change every 48 to 72 based on total daily insulin usage.Documentation of positive clinical response.The number of pods prescribed over time corresponds to the estimated total daily insulin usage.For continuation of Omnipod therapy, defined as no more than a 45-day gap in therapy AND. ![]() Patient has used at least three injections of insulin per day involving self-adjustments of insulin dosage for at least six months.Patient (or someone assisting the individual) is capable of managing the pump and adjusting insulin doses as needed.Patient completed a diabetes education program within the preceding 24 months.Prescriber attests to one of the following:.Prescribed by or in consultation with a diabetes educator or endocrinologist AND.Diagnosis of diabetes (i.e., type I, type II, LADA) that requires multiple daily injections of insulin (i.e., three or more daily) AND.To be covered, members must meet specific coverage criteria. Insulin Pump Therapy (Omnipod DASH, Omnipod 5)ĭiabetes mellitus (DM): Individuals with diabetes mellitus who require multiple daily injections of insulin can use external insulin pumps to administer insulin through continuous subcutaneous infusion.
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