Omnipod 5 Added to Medicaid and CHIP Formularies

Date: March 18, 2024

Attention: All Providers

Effective date: February 22, 2024

Call to action: Texas Children’s Health Plan (TCHP) would like to let providers know that effective February 22, 2024, the Texas Health and Human Services (HHSC) allows coverage for Omnipod 5 through pharmacy benefit for both CHIP and Medicaid formularies. Members can obtain one (1) Omnipod 5 G6 intro kit per 365 days, and fifteen (15) units of Omnipod 5 C6 PODS per 30 days. HHSC is not requiring clinical prior authorization for Omnipod 5 at this time.

How this impacts providers: The change will allow providers to prescribe Omnipod 5 through pharmacy benefit. Other insulin delivery systems and glucose monitors, including Omnipod DASH, must continue to be billed through the medical benefit.

Although HHSC has not implemented prior authorization criteria at this time, it is possible they will require criteria similar to the medical benefit (see below). Providers should adhere to the medical criteria in the event of a future benefit update from HHSC. The Provider Alert with the latest update is:

• Provider Alert! Diabetic Equipment and Supplies-Home Health Policy & Monitoring Update – The Checkup

Next step for Providers: Prescribers should share this communication with their staff.

Resources:

• Provider Alert! Diabetic Equipment and Supplies-Home Health Policy & Monitoring Update – The Checkup
• Texas Medicaid Provider Procedures Manual | TMHP
  • Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook
  • Durable Medical Equipment, Medical Supplies, and Nutritional Products Handbook

If you have any questions, please email TCHP Pharmacy at: tchppharmacy@texaschildrens.org.

For access to all provider alerts,log into:
www.thecheckup.org or www.texaschildrenshealthplan.org/for-providers.