Medical Coverage Policy | Glucose Monitoring -Home - Non-OneTouch Brand
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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 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.
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.
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.
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
Coding and Modifiers
| 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 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
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
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
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.
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.
Policy effective date published as 06/01/2021.
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