Hot Tip: DME Products — Non‑preferred disposable insulin delivery devices and continuous glucose monitoring (CGM) systems
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Guidance for prescribing and pharmacy processing of non-preferred durable medical equipment products (notably disposable insulin delivery devices and continuous glucose monitoring systems) for Healthy Blue and Healthy Blue Care Together members of Blue Cross and Blue Shield of North Carolina.
No material clinical or coverage changes in this revision.
Coverage Criteria and Scope
Coverage criteria and administrative requirements
Coverage and administrative rules for listed DME products
Preferred Drug List is updated quarterly by NC DHHS; verify on provider.healthybluenc.com
See footnote 1
See footnote 2
See product NDC and quantity limit listings
The Hot Tip does not list explicit clinical exclusions for the enumerated devices. Instead, coverage guidance focuses on administrative expectations: verify product coverage via the Healthy Blue Preferred Drug List and follow the plan’s prior authorization and preferred‑product trial rules where applicable. Failure to meet these administrative requirements (for example, not completing required prior authorization or not documenting required preferred‑product trials) may result in noncoverage or claim denial.
This policy’s emphasis is administrative rather than clinical: it highlights that prior authorization is required for continuous glucose monitoring system products and that nonpreferred products require documentation of a trial and failure of two preferred products before coverage. Providers should therefore prioritize completing the specified authorization and step‑therapy steps and documenting product selection to avoid pharmacy delays.
Coding, NDCs, and Quantity Limits
| 08508200005 | NDC listed for disposable insulin delivery devices |
| 08508300021 | NDC listed for disposable insulin delivery devices |
| 08508300053 | NDC listed for disposable insulin delivery devices |
| 08508300075 | NDC listed for disposable insulin delivery devices |
| 08508300042 | NDC listed for disposable insulin delivery devices |
| 08508300088 | NDC listed for disposable insulin delivery devices |
| 08508300001 | NDC listed for disposable insulin delivery devices |
| 08508300050 | NDC listed for disposable insulin delivery devices |
| 08508200032 | NDC listed for disposable insulin delivery devices |
| 08508400010 | NDC listed for disposable insulin delivery devices |
| 50050010210 | NDC listed for Ilet infusion kit (32' 6mm) |
| 50050010215 | NDC listed for Ilet infusion kit (32' 6mm) |
| 08627005303 | Dexcom G6 sensor NDC |
| 08627007701 | Dexcom G7 sensor NDC |
| 08627007901 | Dexcom G7 15-day sensor NDC |
| 57599080000 | Freestyle Libre 2 system sensor kit NDC |
| 57599081800 | Freestyle Libre 3 system sensor kit NDC |
| 57599083500 | Freestyle Libre 2 Plus sensor NDC |
| 57599084400 | Freestyle Libre 3 Plus sensor NDC |
| 57599000101 | Freestyle Libre 14 Day sensor 1-kit NDC |
| 08627001601 | Dexcom G6 transmitter NDC |
| 08627009111 | Dexcom G6 receiver NDC |
| 08627007801 | Dexcom G7 receiver NDC |
| 57599080300 | Freestyle Libre 2 system reader NDC |
| 57599082000 | Freestyle Libre 3 system reader NDC |
| 57599000200 | Freestyle Libre 14 Day reader NDC |
Prior Authorization, Step Therapy, and Prescriber Responsibilities
Obtain prior authorization for CGM products
Prior authorization is required for continuous glucose monitoring (CGM) system products; obtain prior authorization before dispensing or billing these devices.
Trial preferred products when policy indicates nonpreferred status
Some listed devices are nonpreferred; providers must trial preferred products before prescribing nonpreferred devices when the policy requires it.
- Verify whether a product is labeled nonpreferred on the Healthy Blue Preferred Drug List.
- If nonpreferred, follow the policy’s trial requirements (see step therapy block).
Step therapy — two preferred-product failures required
For nonpreferred DME products designated in the Hot Tip, the policy requires trial and failure of two preferred products prior to coverage; document prior trials and failures in the member’s record.
- Document dates, products used, clinical response, and reason for failure for two preferred products.
- Coverage will not be approved until the two-preferred-product trial-and-failure requirement is met for nonpreferred items.
Document product selection and verify Preferred Drug List
Document the rationale for product selection and any clinical criteria met; verify coverage on the Healthy Blue Preferred Drug List (updated quarterly) and include that verification in the record.
- Record the selected product, clinical indication, and which coverage criteria (if any) were met.
- Note verification of coverage from the Preferred Drug List (provider.healthybluenc.com) and retain evidence of verification.
Non-preferred product prescribing may trigger pharmacy delays
Prescribing non-preferred DME products may require additional pharmacy steps or authorization checks and can delay dispensing; consider prescribing preferred products to avoid these delays.
- Confirm preferred status before prescribing to minimize pharmacy delays.
- Be prepared to provide documentation of clinical criteria or prior trials if dispensing is delayed.
Not obtaining prior authorization for CGM risks denial
Failure to obtain required prior authorization for continuous glucose monitoring system products risks denial of coverage and payment.
- Do not dispense or bill for CGM devices without prior authorization; lack of prior auth may result in claim denial.
Administrative Medical Necessity Criteria
Administrative necessity criteria
Administrative medical necessity steps
Footnote 1: Prior authorization is required for continuous glucose monitoring system products.
See Preferred Drug List and footnote 2
Preferred Drug List available at provider.healthybluenc.com and updated quarterly; documenting trial/failure supports prior authorization/coverage decisions.
Failure to obtain required prior authorization risks denial of coverage.
Documentation and Verification Requirements
Verify Preferred Drug List, obtain prior auth, and document two preferred-product failures when required
Check the Healthy Blue Preferred Drug List and obtain prior authorization for CGM products when required; for nonpreferred items, document trial and failure of two preferred products as part of the prior authorization or medical record.
- Verify coverage on the Preferred Drug List at provider.healthybluenc.com (updated quarterly).
- Include documentation of two preferred-product trials and reasons for failure when requesting coverage for nonpreferred products.
Background and Scope Summary
Background: this Hot Tip enumerates specific disposable insulin delivery devices and continuous glucose monitoring components commonly used by members. Covered disposable insulin delivery devices include branded pod and infusion kit products such as Omnipod Dash, Omnipod 5 (G6/G7) series, Omnipod GO, Cequr Simplicity, and Ilet infusion kits. The document also lists blood glucose system sensors, transmitters, and readers from Dexcom and Freestyle Libre product lines (for example, Dexcom G6/G7 sensors and transmitters, and Freestyle Libre 2/3 and 14‑day sensors and readers).
Device Definitions
Coverage Limitations and Denial Risk
Not covered: the Hot Tip does not provide a discrete list of items that are categorically not covered. Instead, it makes clear that coverage may be denied when required administrative steps are not followed — for example, failure to obtain prior authorization for CGM products or failure to document the required trial and failure of two preferred products for nonpreferred items.
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