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Insulin Syringes, Needles, Alcohol Swabs, Gauze Pads Prior Authorization Criteria - Medicare Part D
Medicare Utilization Management Policy
Version Date: 01/01/2025

Prior Authorization Criteria for Approval

This program will be implemented as a dynamic PA

Alcohol Swabs, Gauze Pads, Insulin Syringe/Needle, Insulin Pen Needle will be approved when BOTH of the following are met:

  1. The requested medical supply product will be used in the delivery of insulin to the body
    AND
  2. The patient’s medication history includes use of insulin within the past 180 days

Length of Approval: 12 months
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