Insulin-treated diabetes (third class)

Your step-by-step plan

1. 1

   Step 1: Your history

   Past low blood sugar episodes, and time stable on your current treatment.

   At least 6 months clinically stable on your current treatment, and no history of the low blood sugar episodes below.

   Low blood sugar (hypoglycemia)

   • No recurrent episodes (two or more) in the past 5 years, and none in the past year, that caused loss of consciousness, a seizure or impaired thinking, needed help from another person, or came without warning (hypoglycemia unawareness)

   Stable

   • Clinically stable on your current treatment for 6 months or more

   Show the FAA's words: Your history

   The applicant must have had no recurrent (two or more) episodes of hypoglycemia in the past 5 years and none in the preceding 1 year which resulted in loss of consciousness, seizure, impaired cognitive function or requiring intervention by another party, or occurring without warning (hypoglycemia unawareness).

   FAA source: Guide for Aviation Medical Examiners – Insulin Treated, non-CGM third class – Initial Certification. FAA date 10 March 2023; checked by Crosscheck 14 October 2026.

   Consideration will be given only to those individuals who have been clinically stable on their current treatment regimen for a period of 6-months or more.

   FAA source: Guide for Aviation Medical Examiners – Diabetes Mellitus, Insulin Treated (non-CGM, third-class option). FAA date 9 March 2023; checked by Crosscheck 14 October 2026.

2. 2

   Step 2: Medical, accident and incident records

   Copies of the records pertinent to your history of diabetes.

   Copies of your medical records, and of accident and incident records, pertinent to your history of diabetes.

   Show the FAA's words: Medical, accident and incident records

   The applicant should provide copies of medical records as well as accident and incident records pertinent to their history of diabetes.

   FAA source: Guide for Aviation Medical Examiners – Insulin Treated, non-CGM third class – Initial Certification. FAA date 10 March 2023; checked by Crosscheck 14 October 2026.

3. 3

   Step 3: The examination

   A complete medical examination report, what it includes, and the form the FAA prefers.Two things to bring

   • Medical examination report

     Within 90 days before the exam

     A report of a complete medical examination, performed within the past 90 days, preferably by a physician who specializes in treating diabetes.

     The FAA prefers its Initial Comprehensive Report form. Any report must include at least what is below.

     Any report, at a minimum

     • Two A1C measurements, with the laboratory reference range, at least 90 days apart, the most recent no more than 90 days old
     • Your insulin dosages and diet
     • Whether there is cerebrovascular, cardiovascular or peripheral vascular disease, or neuropathy
     • An eye specialist's confirmation of no clinically significant eye disease
     • That you have been educated in diabetes and its control, and know what to do if complications, especially low blood sugar (hypoglycemia), arise
     • That you are able and willing to monitor and manage your diabetes
     • From age 40, a maximal graded exercise stress test report, with ECG tracings
     • A statement on your dexterity and ability to check your blood glucose with a recording glucometer

   • The Initial Comprehensive Report

     Within 90 days before the exam

     The FAA's Initial Comprehensive Report, from your treating board-certified endocrinologist, performed within the past 90 days. The FAA prefers this form.

     Either this form or another complete examination report.

     Diabetes history

     • Onset, past treatment and hospitalizations
     • Complications and other conditions
     • Lifestyle: eating, weight, sleep, activity, carbohydrate counting, tobacco, alcohol, substances, and any motor vehicle accidents or incidents
     • Medications: compliance, side effects, alternative medicine
     • Glucose monitoring results and pump settings
     • Screens for depression, anxiety, disordered eating and cognition
     • Diabetes education and barriers to self-management
     • Lows and highs in the past 12 months

     Sustained lows, for example: under 70 for over 30 minutes, or under 54 for over 15. Sustained highs, for example: over 250 for over 60 minutes, or over 300 for over 30.

     Physical exam

     • Height, weight and BMI
     • Pulse and blood pressure, standing (orthostatic) when indicated
     • Thyroid and skin exam
     • A full foot exam: pulses, sensation and the 10-g monofilament test

     Assessment and plan

     • Current status: compliance, control, stability, and your ability to monitor, respond to lows and highs, and give insulin
     • Prognosis for the next 12 months
     • Recommended treatment changes
     • The date of the next follow-up, every 3 months for the FAA

   Show the FAA's words: The examination

   A report of a complete medical examination, preferably by a physician who specializes in the treatment of diabetes, will be required. The exam must be performed within the past 90 days . The Initial Comprehensive Report ( PDF ) , which outlines our requirements, is preferred, however, ANY report submitted MUST include, as a minimum:

   Two measurements of glycosylated hemoglobin (total A 1 or A 1c concentration and the laboratory reference range), separated by at least 90 days. The most recent measurement must be no more than 90 days old.

   Specific reference to the applicant's insulin dosages and diet.

   Specific reference to the presence or absence of cerebrovascular, cardiovascular, or peripheral vascular disease or neuropathy.

   Confirmation by an eye specialist of the absence of clinically significant eye disease.

   Verification that the applicant has been educated in diabetes and its control and understands the actions that should be taken if complications, especially hypoglycemia, should arise. The examining physician must also verify that the applicant has the ability and willingness to properly monitor and manage his or her diabetes.

   If the applicant is age 40 or older, a report, with ECG tracings, of a maximal graded exercise stress test.

   The applicant shall submit a statement from his/her treating physician, Examiner, or other knowledgeable person attesting to the applicant's dexterity and ability to determine blood glucose levels using a recording glucometer.

   FAA source: Guide for Aviation Medical Examiners – Insulin Treated, non-CGM third class – Initial Certification. FAA date 10 March 2023; checked by Crosscheck 14 October 2026.

   ANY report submitted MUST include, as a minimum:

   …Specific reference to the applicant's insulin dosages and diet.

   FAA source: Guide for Aviation Medical Examiners – Insulin Treated, non-CGM third class – Initial Certification. FAA date 10 March 2023; checked by Crosscheck 14 October 2026.

   ANY report submitted MUST include, as a minimum:

   …Specific reference to the presence or absence of cerebrovascular, cardiovascular, or peripheral vascular disease or neuropathy.

   FAA source: Guide for Aviation Medical Examiners – Insulin Treated, non-CGM third class – Initial Certification. FAA date 10 March 2023; checked by Crosscheck 14 October 2026.

   ANY report submitted MUST include, as a minimum:

   …Verification that the applicant has been educated in diabetes and its control and understands the actions that should be taken if complications, especially hypoglycemia, should arise. The examining physician must also verify that the applicant has the ability and willingness to properly monitor and manage his or her diabetes.

   FAA source: Guide for Aviation Medical Examiners – Insulin Treated, non-CGM third class – Initial Certification. FAA date 10 March 2023; checked by Crosscheck 14 October 2026.

   INITIAL COMPREHENSIVE REPORT

   …The INITIAL COMPREHENSIVE REPORT performed within the past 90 days from the treating board-certified endocrinologist must detail and comment on ALL of the following *1

   A. DIABETES HISTORY:

   1. Characteristics at onset (age, symptoms, etc.):

   a) Review previous treatment and response

   b) Frequency/cause/severity of past hospitalizations

   c) Complications and common comorbidities:

   Any end organ damage (macrovascular or microvascular);

   Presence of hemoglobinopathies or anemias;

   High blood pressure or abnormal lipids and treatment; and

   Visits to specialist - type and why

   d) Lifestyle and behavior patterns:

   Eating patterns and weight history;

   Sleep behavior and physical activity;

   Familiarity with carbohydrate counting, if applicable;

   Tobacco, alcohol, and substance use; and

   Any motor vehicle accidents or incidents pertinent to their history of diabetes

   2. Medication and Reporting:

   a) Medication compliance;

   b) Medication intolerance or side effects;

   c) Complementary or alternative medicine use;

   d) Glucose monitoring (meter/CGM): results and data use; and

   e) Review insulin pump settings

   3. Screening for Psychosocial conditions:

   a) Screen for depression, anxiety, disordered eating (ex: Patient Health Questionnaire 9 or 2 [PHQ-9 or PHQ-2] or similar);

   b) Cognitive impairment assessment (and formal testing, if clinically indicated); and

   c) Diabetes self-management education and support:

   History of dietician/diabetes educator visits; and

   Screen for barriers to diabetes self-management

   4. Glucose control:

   a) Hypoglycemia:

   Any symptomatic episodes in the past 12 months requiring treatment or assistance by another individual, with comment on timing, awareness, frequency, causes, and treatment.

   Sustained episodes, e.g. CGM/FSBG values below 70 mg/dL for over 30 minutes or below 54 mg/dL for over 15 minutes, with comment on symptoms and treatment.

   b) Hyperglycemia:

   Any symptomatic episodes in the past 12 months with comment on timing, awareness, frequency, causes, and treatment.

   Sustained episodes, e.g. CGM/FSBG values above 250 mg/dL for over 60 minutes or above 300 mg/dL for over 30 minutes, with comment on symptoms and treatment.

   B. PHYSICAL EXAM (Must narrate what is examined and any findings):

   1. Height, Weight, Body Mass Index (BMI);

   2. Pulse and blood pressure including orthostatic blood pressure, when indicated;

   …3. Thyroid palpation and skin exam (acanthosis nigricans, insulin injection or insertion sites, lipodystrophy); and

   4. Comprehensive foot exam:

   a) Visual inspection; screen for PAD (check pedal pulses; refer for ABI if diminished); and

   b) Determination of temperature, vibration or pinprick sensation, and 10-g monofilament exam

   C. ASSESSMENT AND PLAN:

   1. Current status of diabetes including an assessment of the airman’s compliance, glucose control, and stability as well as their ability to monitor and respond accordingly to HYPO and HYPER glycemic events and administer insulin doses;

   2. Prognosis for progression over the next 12 months; and

   3. Recommendations for treatment changes

   D. DATE OF NEXT CLINICAL FOLLOW-UP (Required every 3 months for FAA.)

   FAA source: Insulin Treated Diabetes – Initial Comprehensive Report (non-CGM, third-class option). FAA date 30 September 2020; checked by Crosscheck 14 October 2026.

   The Initial Comprehensive Report ( PDF ) , which outlines our requirements, is preferred

   FAA source: Guide for Aviation Medical Examiners – Insulin Treated, non-CGM third class – Initial Certification. FAA date 10 March 2023; checked by Crosscheck 14 October 2026.

4. 4

   Step 4: Two A1Cs

   At least 90 days apart, and the most recent no more than 90 days old.

   Two A1C measurements, with the laboratory reference range, at least 90 days apart. The most recent no more than 90 days old.

   Show the FAA's words: Two A1Cs

   ANY report submitted MUST include, as a minimum:

   Two measurements of glycosylated hemoglobin (total A 1 or A 1c concentration and the laboratory reference range), separated by at least 90 days. The most recent measurement must be no more than 90 days old.

   FAA source: Guide for Aviation Medical Examiners – Insulin Treated, non-CGM third class – Initial Certification. FAA date 10 March 2023; checked by Crosscheck 14 October 2026.

5. 5

   Step 5: Eye specialist

   Confirmation of the absence of clinically significant eye disease.

   An eye specialist's confirmation that there is no clinically significant eye disease.

   Show the FAA's words: Eye specialist

   ANY report submitted MUST include, as a minimum:

   …Confirmation by an eye specialist of the absence of clinically significant eye disease.

   FAA source: Guide for Aviation Medical Examiners – Insulin Treated, non-CGM third class – Initial Certification. FAA date 10 March 2023; checked by Crosscheck 14 October 2026.

6. 6

   Step 6: Stress test

   From age 40, the report, with ECG tracings, of a maximal graded exercise stress test.One question inside

   Are you 40 or older?

   Are you 40 or older?

   This protocol asks for a stress test from age 40.

   40 or olderUnder 40

   From age 40: a report, with ECG tracings, of a maximal graded exercise stress test.

   The test

   • 100% of predicted maximum heart rate, unless symptoms, medications or a medical reason prevent it
   • Complete Stage 3, at least 9 minutes
   • The worksheet, the interpretive report and all the actual ECG tracings: at rest, every stage, peak and recovery

   Under 85% of maximum heart rate and under 9 minutes (6 from age 70) may lead to denial. Computer-generated sample tracings are not accepted in place of the actual ones.

   The FAA asks that beta blockers, diltiazem, verapamil and digitalis be held 24–48 hours before the test, unless contraindicated and only with your treating physician's consent. If they are not, the cardiologist explains why.

   With a bundle branch block, LVH or diffuse ST/T wave changes at rest, the FAA requires a stress echo or nuclear stress test.

   The AME may not issue if the test shows

   • Exercise test: under 85% of predicted maximum heart rate; under 9 minutes (under 6 from age 70); or ST depression of 1 mm or more, unless further evidence, such as a nuclear study or stress echo, reviewed and reported by a qualified cardiologist, shows no reversible ischemia or wall motion abnormalities
   • Nuclear stress test: reversible ischemia, a negative change from the prior study of the same type, an ejection fraction of 40% or less, or a fall of 10% or more from a prior study
   • Stress echo: exercise-induced wall motion abnormalities, a negative change from the prior study of the same type, an ejection fraction of 40% or less, or a fall of 10% or more from a prior study

   Show the FAA's words: Stress test

   ANY report submitted MUST include, as a minimum:

   …If the applicant is age 40 or older, a report, with ECG tracings, of a maximal graded exercise stress test.

   FAA source: Guide for Aviation Medical Examiners – Insulin Treated, non-CGM third class – Initial Certification. FAA date 10 March 2023; checked by Crosscheck 14 October 2026.

   GXT requirements:

   100% of predicted maximal heart rate (PMHR), unless medically contraindicated or prevented either by symptoms or medications;

   Complete Stage 3 (equivalent to at least 9 minutes);

   Studies of less than 85% of maximum predicted heart rate and less than 9 minutes of exercise (6 minutes for age 70 or greater) may serve a basis for denial; and

   FAA source: Guide for Aviation Medical Examiners – Graded Exercise Stress Test Requirements. FAA date 29 May 2024; checked by Crosscheck 14 October 2026.

   The worksheet with blood pressure/pulse recordings at various stages, interpretive report, and actual ECG tracings* must be submitted.

   Tracings must include a rhythm strip;

   A full 12-lead ECG recorded at rest - supine and standing. (Anything less than a full 12-lead will not be accepted); and

   One or more times during each stage of exercise, at the end of each stage, at peak exercise, and every minute during recovery for at least 5 minutes or until the tracings return to baseline level.

   *Computer generated, sample-cycle ECG tracings are unacceptable in lieu of the standard tracings. If submitted alone, this may result in deferment until this requirement is met.

   FAA source: Guide for Aviation Medical Examiners – Graded Exercise Stress Test Requirements. FAA date 29 May 2024; checked by Crosscheck 14 October 2026.

   If a plain GXT is required and is uninterpretable for any reason, a radionuclide GXT will then be required before further consideration

   In patients with bundle branch blocks (BBB), LVH, or diffuse ST/T wave changes at rest, a stress echo or nuclear stress test will be required.

   FAA source: Guide for Aviation Medical Examiners – Graded Exercise Stress Test Requirements. FAA date 29 May 2024; checked by Crosscheck 14 October 2026.

   IF ANY OF THE FOLLOWING ARE NOTED, THE AME MAY NOT ISSUE.

   Exercise stress test (EST)

   PMHR less than 85% ; (predicted maximal heart rate)

   Time less than 9 minutes--under age 70;

   Time less than 6 minutes --age 70 or greater

   1 mm ST depression or greater at any time during stress testing - UNLESS the applicant has additional medical evidence such as a nuclear imaging study or a stress echocardiogram showing the absence of reversible ischemia or wall motion abnormalities reviewed and reported by a qualified cardiologist.

   Nuclear stress test

   Evidence of reversible ischemia OR

   Negative change from the prior study of the same type OR

   Ejection Fraction (EF) reported as 40% or less OR

   EF decrease by 10% or more from a prior study

   Stress echo

   Exercised induced wall motion abnormalities (WMA) OR

   Negative change from the prior study of the same type OR

   EF 40% or less OR

   EF decreased by 10% or more from a prior study

   FAA source: Guide for Aviation Medical Examiners – Graded Exercise Stress Test Requirements. FAA date 29 May 2024; checked by Crosscheck 14 October 2026.

   Beta blockers and calcium channel blockers (specifically diltiazem and verapamil) or digitalis preparations should be discontinued for 24-48 hours prior to testing (if not contraindicated and only with the consent of the treating physician) in order to obtain maximum heart rate.

   If the GXT is done on beta blockers, calcium blockers, or digitalis medications, the applicant must provide explanation from the treating cardiologist as to why the medication(s) cannot be held.

   FAA source: Guide for Aviation Medical Examiners – Graded Exercise Stress Test Requirements. FAA date 29 May 2024; checked by Crosscheck 14 October 2026.

   Disease Protocols - Graded Exercise Stress Test Requirements

   FAA source: Guide for Aviation Medical Examiners – Graded Exercise Stress Test Requirements. FAA date 29 May 2024; checked by Crosscheck 14 October 2026.

7. 7

   Step 7: Dexterity statement

   Who writes it, and what it attests to about using a recording glucometer.

   A statement from your treating physician, your AME or another knowledgeable person, attesting to your dexterity and ability to check your blood glucose with a recording glucometer.

   Show the FAA's words: Dexterity statement

   The applicant shall submit a statement from his/her treating physician, Examiner, or other knowledgeable person attesting to the applicant's dexterity and ability to determine blood glucose levels using a recording glucometer.

   FAA source: Guide for Aviation Medical Examiners – Insulin Treated, non-CGM third class – Initial Certification. FAA date 10 March 2023; checked by Crosscheck 14 October 2026.

8. 8

   Step 8: In the cockpit

   What to carry, when to measure blood glucose, and what each reading calls for.

   What to carry in flight, when to check your blood glucose, and what each reading calls for.

   Carry in flight

   • A recording glucometer
   • Supplies to take blood samples
   • Fast-acting glucose in 10 gram portions, enough for the planned flight

   Half an hour before flight

   Under 100 mg/dl

   A glucose snack of at least 10 grams, then check again half an hour later

   100 to 300 mg/dl

   Flight may go ahead

   Over 300 mg/dl

   Cancel the flight

   Still under 100 on the second check: repeat the snack and the check.

   In flight

   Under 100 mg/dl

   A 20 gram glucose snack

   100 to 300 mg/dl

   No action

   Over 300 mg/dl

   Land at the nearest suitable airport

   Check one hour into the flight, every hour after that, and within half an hour before landing. After landing over 300, no further flight until it can be kept between 100 and 300.

   When flying has to come first

   • Use your judgment: measuring, or the demands of flight, such as bad weather
   • Flying first: a 10 gram glucose snack, then measure 1 hour later
   • If measuring then is not practical: a 20 gram snack, and land at the nearest suitable airport to measure

   Show the FAA's words: In the cockpit

   To ensure safe flight, the insulin using diabetic airman must carry during flight a recording glucometer; adequate supplies to obtain blood samples; and an amount of rapidly absorbable glucose, in 10 gm portions, appropriate to the planned duration of the flight.

   FAA source: Guide for Aviation Medical Examiners – Insulin Treated, non-CGM third class – Monitoring and Actions Required During Flight Operations. FAA date 6 November 2019; checked by Crosscheck 14 October 2026.

   One half hour prior to flight, the airman must measure the blood glucose concentration. If it is less than 100 mg/dl the individual must ingest an appropriate (not less than 10 gm) glucose snack and measure the glucose concentration one half hour later. If the concentration is within 100 -- 300 mg/dl, flight operations may be undertaken. If less than 100, the process must be repeated; if over 300, the flight must be canceled.

   FAA source: Guide for Aviation Medical Examiners – Insulin Treated, non-CGM third class – Monitoring and Actions Required During Flight Operations. FAA date 6 November 2019; checked by Crosscheck 14 October 2026.

   One hour into the flight, at each successive hour of flight, and within one half hour prior to landing, the airman must measure their blood glucose concentration. If the concentration is less than 100 mg/dl, a 20 gm glucose snack shall be ingested. If the concentration is 100 -- 300 mg/dl, no action is required. If the concentration is greater that 300 mg/dl, the airman must land at the nearest suitable airport and may not resume flight until the glucose concentration can be maintained in the 100 -- 300 mg/dl range.

   FAA source: Guide for Aviation Medical Examiners – Insulin Treated, non-CGM third class – Monitoring and Actions Required During Flight Operations. FAA date 6 November 2019; checked by Crosscheck 14 October 2026.

   In respect to determining blood glucose concentrations during flight, the airman must use judgment in deciding whether measuring concentrations or operational demands of the environment (e.g., adverse weather, etc.) should take priority. In cases where it is decided that operational demands take priority, the airman must ingest a 10 gm glucose snack and measure his or her blood glucose level 1 hour later. If measurement is not practical at that time, the airman must ingest a 20 gm glucose snack and land at the nearest suitable airport so that a determination of the blood glucose concentration may be made.

   FAA source: Guide for Aviation Medical Examiners – Insulin Treated, non-CGM third class – Monitoring and Actions Required During Flight Operations. FAA date 6 November 2019; checked by Crosscheck 14 October 2026.

9. 9

   Step 9: Student pilots

   A note on medical eligibility before beginning or resuming flight instruction or training.

   Student pilots may wish to make sure they are eligible for a medical certificate before beginning or resuming flight instruction or training.

   Acting as pilot in command takes a valid medical certificate for the type of operation.

   Show the FAA's words: Student pilots

   Note: Student pilots may wish to ensure they are eligible for medical certification prior to beginning or resuming flight instruction or training. In order to serve as a pilot in command, you must have a valid medical certificate for the type of operation performed.

   FAA source: Guide for Aviation Medical Examiners – Insulin Treated, non-CGM third class – Initial Certification. FAA date 10 March 2023; checked by Crosscheck 14 October 2026.