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 related supplies for Blue Cross & Blue Shield of Rhode Island Medicare Advantage members. 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 TypeNo material change

Effective Date05 |01 2024

Next Review Date

Key ActionPrior authorization is required for requests of non-OneTouch branded home blood glucose monitors for Medicare Advantage members; contact PBM at 1-800-693-6651, fax 855-212-8110, or submit via covermymeds.com.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this update.

1Brand limited for Medicare Advantage (OneTouch preferred)

7HCPCS codes listed

500Max strips insulin-treated/3 months

200Max strips non-insulin-treated/3 months

Coverage Summary

This policy governs coverage and prior authorization requirements for non-OneTouch branded home blood glucose monitors and related supplies for Blue Cross & Blue Shield of Rhode Island Medicare Advantage members. Medicare Advantage members have a limited benefit that restricts the preferred brand of home glucose monitors to OneTouch; non-OneTouch devices may be covered only when clinical criteria are met and prior authorization is obtained.

For commercial products there is no brand limitation — all brands of home blood glucose monitors are covered. Medicare Advantage members are brand-limited to OneTouch unless the specified criteria and prior authorization requirements are satisfied.

Insulin-dependent supply limit (3 months)500 units (A4253/A4259)

Non-insulin-dependent supply limit (3 months)200 units (A4253/A4259)

Brand preference (Medicare Advantage)OneTouch preferred; non-OneTouch allowed with PA

Criteria for Coverage (Medicare Advantage — non-OneTouch monitors)

Coverage for non-OneTouch branded home blood glucose monitors (Medicare Advantage only)

Covered when ALL of the following are met:

ALL of the following

Medicare Advantage enrollment: Member is enrolled in a Medicare Advantage product (policy applicable to Medicare Advantage Plans only).
Prior authorization has been obtained from BCBSRI Pharmacy Benefit Management Vendor (contact 1-800-693-6651, fax 855-212-8110, or submit via covermymeds.com).
PBM clinical guidelines met: Clinical guidelines for approval are met per BCBSRI Pharmacy Benefit Management Program at covermymeds.com.

Code Tables

Covered HCPCS for non-OneTouch products when criteria met (Medicare Advantage)HCPCSCovered

A4253	Blood glucose test or reagent for home blood glucose monitor, per 50 strips
A4259	Lancets, per box of 100
A4271	Integrated lancing and blood sample cartridges for home blood glucose monitor, per 50 tests (New Code Effective 4/1/2024; Text Revision Effective 10/1/2024)
E2100	Blood glucose monitor with integrated voice synthesizer
E0607	Home blood glucose monitor
E2101	Blood glucose monitor with integrated lancing/blood sample
E2104	Home blood glucose monitor for use with integrated lancing/blood sample cartridge (New Code Effective 4/1/2024)

Covered OneTouch products (examples)mixedCovered

	OneTouch Monitor
	OneTouch Verio Flex Meter
	OneTouch Verio Meter
	OneTouch Verio IQ Meter
	OneTouch Ultra Mini Meter
	OneTouch Verio Reflect Meter
	OneTouch test strips (25, 50, or 100 strip box)

What Providers Must Do

Prior Authorization

Prior authorization required for non-OneTouch products

Prior authorization is required for requests of non-OneTouch branded home blood glucose monitors for Medicare Advantage members; contact the PBM at 1-800-693-6651, fax 855-212-8110, or submit via covermymeds.com.

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

Billing Rule

HCPCS/NDC required on claims

Claims must be filed with both the HCPCS code and the NDC for the specific device dispensed to ensure correct claims processing.

Affected HCPCS: A4253, A4259, A4271, E2100, E0607, E2101, E2104

Billing Rule

Modifiers required on every claim

Per CMS guidelines, add modifier KX for insulin-treated beneficiaries and KS for non-insulin-treated beneficiaries on the HCPCS supply code(s); the KX modifier must not be used for beneficiaries who are not treated with insulin injections.

Modifier KX (use if beneficiary is insulin treated)
Modifier KS (use if beneficiary is non-insulin treated)
Note: KX must not be used for beneficiaries not treated with insulin injections

Documentation Required

Follow PBM clinical guideline

Documentation must support that clinical criteria from the BCBSRI Pharmacy Benefit Management Program were met for approval of non-OneTouch products (guidelines available at covermymeds.com).

Reference PBM clinical guidelines at covermymeds.com
Documentation must demonstrate that PBM criteria were met for approval

Billing Rule

Lancet brand limitation

There is no benefit limitation regarding brands of lancets (no brand restriction for lancets).

Lancet HCPCS listed: A4259
No brand restriction for lancets

Definitions & Background

Medicare Advantage Plans have a limited benefit regarding the brand of home blood glucose monitors: the preferred brand is OneTouch. Requests for non-OneTouch branded home blood glucose monitors are covered only when the medical criteria are met and prior authorization is obtained through the BCBSRI Pharmacy Benefit Management Vendor (call 1-800-693-6651, fax 855-212-8110, or submit via covermymeds.com). Commercial products have no brand limitation.

Insulin-treated: Member is receiving insulin injections to treat their diabetes; members taking oral medications are not insulin-treated.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyMedical Coverage Policy Glucose Monitoring Home Non-OneTouch Brand

Policy CodePolicy N/A

Change TypeNo material change

Effective Date05 |01 2024

Next Review Date

SourceLink

On This Page

OpenPayer

Medical Coverage Policy Glucose Monitoring Home Non-OneTouch Brand

Coverage Summary

Criteria for Coverage (Medicare Advantage — non-OneTouch monitors)

Code Tables

What Providers Must Do

Definitions & Background

Revision History