Pharmacy Prior Authorization Criteria

Insulin Delivery Systems

Indications for Prior Authorization

Criteria

Insulin dosers, cartridges, or pen devices

Administrative

• Will be approved, except when excluded as a plan benefit, based on one of the following criteria:
• The patient has visual impairment (unable to use insulin vial and syringe)
OR
• The patient has physical impairment (unable to use insulin vial and syringe)

P & T Revisions

2024-06-05, 2023-05-25, 2022-06-17, 2021-08-31, 2021-05-19, 2021-05-19

References

Revision History

• 2024-06-05: 2024 Annual Review - no changes
• 2023-05-25: 2023 Annual Review
• 2022-06-17: Annual review: no criteria changes. Added "cartridge" as a search term.
• 2021-08-31: 2021 Annual Review
• 2021-05-19: Addition of EHB formulary to guideline, no changes to criteria. update note
• 2021-05-19: Addition of EHB formulary to guideline, no changes to criteria