CurrentAspirus ArisePolicy N/A

Diabetic supplies coverage for Medicare Advantage plans

This document lists covered diabetic supplies (glucose meters, test strips, CGMs, insulin delivery devices, and related supplies) for Aspirus Health Plan Medicare Advantage members and indicates benefit part, acquisition channel, quantity limits, and prior authorization requirements.

Policy Summary

PayerAspirus Arise

PolicyDiabetic supplies coverage for Medicare Advantage plans

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization for specified CGMs and Omnipod devices (Dexcom, Freestyle Libre, Omnipod and Omnipod cartridges).

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Multipledevice categories

Someprior auth required

No QLquantity limits

Part B / Dbenefit parts

Covered Diabetic Supplies and Devices

Glucose meters and test strips

Covered when the specific product and acquisition channel match the listed benefit part and quantity guidance:

Accu-Chek Guide meter and test strips are covered under Part B

Can be obtained through pharmacy or Aspirus Health Plan contracted DME provider

Quantity limit: No QL

Continuous Glucose Monitors

Covered with criteria and prior authorization where noted:

ALL of the following

Policy Summary

PayerAspirus Arise

PolicyDiabetic supplies coverage for Medicare Advantage plans

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization for specified CGMs and Omnipod devices (Dexcom, Freestyle Libre, Omnipod and Omnipod cartridges).

SourceLink

On This Page

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Ancillary supplies

Ancillary supplies are covered as indicated by product category:

ALL of the following

Benefit Covered Under = Part B
Can obtain through pharmacy or Aspirus Health Plan contracted DME provider
Quantity limit: No QL

ALL of the following

Benefit Covered Under = Part D
Can obtain through pharmacy or Aspirus Health Plan contracted DME provider
Quantity limit: No QL

ALL of the following

Benefit Covered Under = Part D
Can obtain through pharmacy
Quantity limit: No QL

Coding, DME Keys, and Quantity Limits

DME keymixed

No codes listed

Quantity limits

Quantity limits summaryNo QL for many items (e.g., Accu-Chek Guide meter and test strips; insulin pumps and pump supplies; lancets; needles; alcohol swabs). See formulary for QL where noted (e.g., Dexcom CGM, Freestyle Libre CGM, Omnipod and Omnipod cartridges).

Items explicitly listed with No QLAccu-Chek Guide (meter and test strips) — No QL; Insulin pumps and insulin pump supplies — No QL; Lancets and lancet devices — No QL; Needles and syringes — No QL; Alcohol swabs/gauze/other misc. supplies — No QL.

Items referencing formulary QLDexcom CGM — See formulary for QL; Freestyle Libre CGM — See formulary for QL; Omnipod and Omnipod cartridges — See formulary for QL.

Where to find QL detailsRefer to the plan formulary for specific quantity limits on CGMs and Omnipod cartridges as noted in the document.

Prior Authorization and Provider Requirements

Prior Authorization

Prior authorization required for Dexcom, Freestyle Libre, and Omnipod (including cartridges)

Dexcom continuous glucose monitors, Freestyle Libre continuous glucose monitors, and Omnipod devices (including Omnipod cartridges) require prior authorization before coverage is provided.

Dexcom — “requires prior authorization” (Benefit Covered Under = Part B)
Freestyle Libre — “requires prior authorization” (Benefit Covered Under = Part B)
Omnipod and Omnipod cartridges — “requires prior authorization” (Benefit Covered Under = Part D)

Benefit Placement and Acquisition Channels

Benefit Covered Under

PurposeIndicates whether a diabetic supply item is covered under Medicare Part B or Part D.

Examples — Part BAccu-Chek Guide (meter and test strips) — Part B; Dexcom CGM — Part B; Freestyle Libre CGM — Part B; Insulin pumps and insulin pump supplies — Part B; Lancets and lancet devices — Part B.

Examples — Part DOmnipod and Omnipod cartridges — Part D; Needles and syringes — Part D; Alcohol swabs/gauze/other misc. supplies — Part D.

Can Obtain Through

DefinitionIndicates the acquisition channel for the item: Pharmacy or Aspirus Health Plan contracted DME provider.

Pharmacy acquisition examplesAccu-Chek Guide — Pharmacy or contracted DME provider; Dexcom CGM — Pharmacy or contracted DME provider; Freestyle Libre CGM — Pharmacy or contracted DME provider; Omnipod and Omnipod cartridges — Pharmacy; Alcohol swabs/gauze/other misc. supplies — Pharmacy.

Contracted DME provider examplesAccu-Chek Guide — Pharmacy or Aspirus Health Plan contracted DME provider; Dexcom CGM — Pharmacy or Aspirus Health Plan contracted DME provider; Freestyle Libre CGM — Pharmacy or Aspirus Health Plan contracted DME provider; Insulin pumps and pump supplies — Aspirus Health Plan contracted DME provider; Lancets and lancet devices — Pharmacy or contracted DME provider; Needles and syringes — Pharmacy or contracted DME provider.