CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Medical Coverage Policy | Glucose Monitoring -Home - Non-OneTouch Brand

Policy governs coverage and prior authorization requirements for non-OneTouch branded home blood glucose monitors and supplies for Medicare Advantage members; OneTouch branded products are the preferred covered brand without restriction. Commercial products have no brand limitation.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyMedical Coverage Policy | Glucose Monitoring -Home - Non-OneTouch Brand

Policy CodePolicy N/A

Change TypeClarified & Revised (administrative and effective-date updates)

Effective Date06/01/2021

Next Review Date

Key ActionObtain prior authorization from BCBSRI Pharmacy Benefit Management Vendor before dispensing non-OneTouch branded blood glucose monitors or supplies; contact 1-800-693-6651, fax 855-212-8110, or submit via covermymeds.com.

SourceLink

POLICY UPDATE CHANGES

Policy specifies that non-OneTouch branded products require prior authorization and clinical criteria on covermymeds.com for Medicare Advantage members.

Two OneTouch Verio models (Sync and Reflect) noted as effective 2021-01-01 in covered OneTouch products list.

1Preferred brand mandated for MA (OneTouch)

8Example OneTouch monitor models listed

5Covered HCPCS codes listed

Coverage Summary

Scope: Medicare Advantage only — the policy limits the brands of home blood glucose monitors available to Medicare Advantage members; the preferred brand is OneTouch. Non-OneTouch devices for Medicare Advantage members may be covered only with prior authorization and when specific PBM clinical criteria are met. Commercial products have no brand limitation. Status: CURRENT. Effective date: 2021-06-01; Last review: 2022-04-06.

Diabetic Testing Supply Limits and Quick Facts

thresholdsInsulin-dependent: 500 units per 3 months (A4253/A4259); Non-insulin-dependent: 200 units per 3 months (A4253/A4259)

statsPreferred brand mandated for MA: OneTouch (policy applies to Medicare Advantage only)

statsExample OneTouch monitor models listed: 8 (OneTouch Monitor; Verio Flex; Verio; Verio IQ; Ultra 2; Ultra Mini; Verio Sync; Verio Reflect)

statsCovered HCPCS codes listed: 5 (A4253, A4259, E0607, E2100, E2101)

Medical Necessity / Coverage Criteria

Coverage for non-OneTouch branded products (Medicare Advantage)

Covered when ALL of the following are met:

ALL of the following

Medicare Advantage enrollment: Member is enrolled in a Medicare Advantage Plan (policy applicable to Medicare Advantage Plans only).
Prior authorization for non-OneTouch branded product has been obtained from BCBSRI Pharmacy Benefit Management Vendor.
Contact 1-800-693-6651, fax 855-212-8110, or covermymeds.com
Clinical criteria: Medical criteria as documented on BCBSRI Pharmacy Benefit Management Program website at covermymeds.com are met.

Coding and Modifiers

Covered HCPCS when medical criteria met (Medicare Advantage)HCPCSCovered

A4253	Blood glucose test or reagent strips for home blood glucose monitor, per 50 strips
A4259	Lancets, per box of 100
E0607	Home blood glucose monitor
E2100	Blood glucose monitor with integrated voice synthesizer
E2101	Blood glucose monitor with integrated lancing/blood sample

Modifiers required for claimsModifier

KX	Use if the beneficiary/member is insulin treated (must not be used for non-insulin treated members)
KS	Use if the beneficiary/member is non-insulin treated

Provider Actions & Billing Requirements

Prior Authorization

Prior authorization required for non-OneTouch products (Medicare Advantage)

Prior authorization is required for any non-OneTouch branded home blood glucose monitor or supplies for Medicare Advantage members. Obtain authorization from the BCBSRI Pharmacy Benefit Management Vendor before dispensing.

Phone: 1-800-693-6651
Fax: 855-212-8110
Online: covermymeds.com

Billing Rule

File claims with HCPCS and NDC

Claims for blood glucose monitors and supplies must be filed with both the appropriate HCPCS code and the NDC for the device dispensed to ensure correct claims processing.

Background

Background: Medicare Advantage plans have a limited benefit regarding which brands of home blood glucose monitors members may obtain; OneTouch is the preferred brand. For non-OneTouch branded products, prior authorization from the BCBSRI Pharmacy Benefit Management Vendor is required and clinical approval criteria on the PBM website at covermymeds.com must be met; contact 1-800-693-6651, fax 855-212-8110, or submit via covermymeds.com. Commercial products have no brand limitation and all brands are covered for commercial members.

Definition: Insulin-treated / Insulin dependent — the member is receiving insulin injections to treat their diabetes; oral medications alone do not qualify as insulin-treated.

Revision History

clarified

Policy specifies that non-OneTouch branded products require prior authorization and that clinical criteria for coverage are documented on BCBSRI Pharmacy Benefit Management Program's website at covermymeds.com; administrative contact and submission methods provided (phone 1-800-693-6651, fax 855-212-8110, or covermymeds.com). This change was marked material/clarified in the policy changes.

2021-01-01revised

Effective dates for Two OneTouch Verio models added to the covered OneTouch products list: OneTouch Verio Sync Meter and OneTouch Verio Reflect Meter noted as Effective 1/1/2021.

2021-06-01policy_effectiveLatest

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyMedical Coverage Policy | Glucose Monitoring -Home - Non-OneTouch Brand

Policy CodePolicy N/A

Change TypeClarified & Revised (administrative and effective-date updates)

Effective Date06/01/2021

Next Review Date

SourceLink

On This Page

Coverage for OneTouch branded products

Covered when ANY of the following (OneTouch brand examples):

OneTouch products list

OneTouch Monitor
Verio Flex: OneTouch Verio® Flex Meter
Verio Meter: OneTouch Verio® Meter
Verio IQ: OneTouch Verio® IQ Meter
Ultra 2: OneTouch Ultra® 2 Meter
Ultra Mini: OneTouch Ultra® Mini Meter
Verio Sync: OneTouch Verio® Sync Meter
Effective 1/1/2021
Verio Reflect: OneTouch Verio® Reflect Meter
Effective 1/1/2021
OneTouch Test Strips - see quantity limits
Ultra Test Strips: OneTouch Ultra® Test Strips - 25, 50 or 100 strip box
Verio Test Strips: OneTouch Verio® Test Strips - 25, 50 or 100 strip box

Lancets

Covered status

Lancets (A4259) have no brand benefit limitation and are covered.

Billing Rule

Modifier reporting requirement

Per CMS guidelines, add modifier KX for beneficiaries who are insulin treated and modifier KS for those who are non-insulin treated on every claim for blood glucose monitoring equipment and related supplies. Do not use the KX modifier for members who are not treated with insulin injections.

KX — use if beneficiary/member is insulin treated (must not be used for non-insulin injection members)
KS — use if beneficiary/member is non-insulin treated

Billing Rule

Test strip / lancet quantity limits

Adhere to unit limits for test strips and lancets when billing HCPCS A4253 and A4259: insulin-dependent members — 500 units per 3 months; non-insulin-dependent members — 200 units per 3 months.

A4253 — Blood glucose test or reagent strips (per 50 strips)
A4259 — Lancets (per box of 100)

Policy effective date published as 06/01/2021.