FLASH: Medicare Omnipod Coverage and Prior Authorization

Effective 7/1/24, Health Alliance™ added Omnipod insulin pods to the Medicare Part D formulary. Coverage of Omnipods does require Prior Authorization.

Requests for prior authorization should be submitted to the Health Alliance Pharmacy department through the GuidingCare portal. Members will be approved for coverage if they meet the CMS Local Coverage Determination criteria for external infusion pumps as well as if the member meets medical necessity for the need of a tubeless pump.

Requests for the use of an Omnipod for Medicare members should NOT be submitted to the Health Alliance Utilization Management department, Commercial members will continue to submit request to Health Alliance Utilization Management.

Please reach out to your Provider Relations Specialist with any questions.