CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Glucose Monitoring - Home - Non-OneTouch Brand

Policy governing coverage and prior authorization requirements for non-OneTouch branded home blood glucose monitors and supplies for Medicare Advantage members of Blue Cross & Blue Shield of Rhode Island; commercial products are not brand-limited.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyGlucose Monitoring - Home - Non-OneTouch Brand

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJun 1, 2021

Next Review DateN/A

Key ActionObtain prior authorization via the BCBSRI PBM (covermymeds.com or contact vendor) and include HCPCS and NDC on the claim.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

OneTouchPreferred brand (Medicare Advantage)

Prior authNon-OneTouch requirement

500 / 200Test strip limits (3 mo)

A4253,A4259,E0607,E2100,E2101Covered codes when criteria met

Coverage Criteria

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Coverage criteria for non-OneTouch branded devices

Covered when ALL of the following are met:

Medicare Advantage enrollment: Request is for a Medicare Advantage Plan member; this policy applies only to Medicare Advantage Plans which have a limited benefit favoring OneTouch branded home blood glucose monitors.

Prior authorization obtained: Prior authorization is required for non-OneTouch branded home blood glucose monitors and must be obtained via the BCBSRI Pharmacy Benefit Management vendor (covermymeds.com) or by contacting the PBM at 1-800-693-6651 (fax 855-212-8110).

Claim documentation: Claims must be filed with the HCPCS and NDC for the device dispensed; only the listed HCPCS codes are covered when the medical criteria are met.

This policy applies to Medicare Advantage members only; Medicare Advantage Plans have a limited benefit favoring the OneTouch brand for home blood glucose monitors. Commercial products are not brand-limited — the Medicare Advantage brand limitation does not apply to commercial members and all brands are covered for commercial products.

Coding and Supply Limits

Covered HCPCS Codes (when criteria met)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

Diabetic testing supply limits (per 3 months)

Insulin-dependent test strip limit500 units per 3 months (A4253)

Non-insulin-dependent test strip limit200 units per 3 months (A4253)

Lancet limit (insulin-dependent)500 units per 3 months (A4259)

Lancet limit (non-insulin-dependent)200 units per 3 months (A4259)

Provider Actions and Prior Authorization

Prior Authorization

Prior Authorization Required

Prior authorization is required for non-OneTouch branded home blood glucose monitors for Medicare Advantage members. Contact the BCBSRI Pharmacy Benefit Management (PBM) vendor at 1-800-693-6651, submit requests via fax to 855-212-8110, or use covermymeds.com. Failure to obtain prior authorization for non-OneTouch devices may result in claim denial.

Include the HCPCS and NDC for the device dispensed on the claim.
Claims for non-OneTouch products require prior authorization through the PBM (phone/fax/covermymeds).
Lancets (A4259) are not brand-limited and do not require the OneTouch brand restriction.

Note

Brand-Limited Benefit — OneTouch Preferred

Medicare Advantage plans have a brand-limited benefit favoring OneTouch. Requests for non-OneTouch branded meters or test strips must meet the PBM clinical criteria available at covermymeds.com. Commercial plans are not subject to this brand limitation.

OneTouch is the preferred/limited brand for blood glucose meters and test strips under Medicare Advantage.
Non-OneTouch products require meeting PBM clinical criteria for approval.

Billing Rule

Claims Filing and Prior Authorization Submission

When submitting claims or prior authorization requests, include both the HCPCS code and the NDC for the specific device dispensed. Use the PBM submission routes (phone/fax/covermymeds) for prior authorization.

Covered HCPCS codes when criteria met: A4253, A4259, E0607, E2100, E2101.
File claims with HCPCS + NDC to ensure correct processing.
Prior authorization submissions should be routed to the PBM via 1-800-693-6651, fax 855-212-8110, or covermymeds.com.

Denial Risk

Denial Risk for Missing Prior Authorization

If prior authorization is not obtained for a non-OneTouch device, the claim may be denied because the Medicare Advantage benefit is limited to OneTouch unless PBM criteria are satisfied.

Denial risk applies specifically to non-OneTouch branded meters and test strips when prior authorization is missing.
Lancets are not subject to the brand limitation and are not at risk for denial on that basis.

Background

Home blood glucose monitors (glucometers) are portable, battery-operated devices that determine capillary whole blood glucose by exposing a reagent strip to a small blood sample. Devices typically use disposable test strips and may store results for later download; some models include features such as an integrated voice synthesizer or integrated lancing/blood sampling. Insulin-treated refers to members receiving insulin injections.

Definitions

Definition — Insulin-treated

DefinitionInsulin-treated means the member is receiving insulin injections to treat their diabetes; oral medications do not qualify as insulin treatment.

Implication for coverageMembers taking only oral diabetes medications are considered non-insulin-treated for policy limits and criteria.

Note on insulin formInsulin does not exist in an oral form; qualifying treatment is by injection.

Medical Necessity

DME medical necessity for non-OneTouch devices

Non-OneTouch products (Medicare Advantage) are covered only when the following medical necessity conditions are satisfied:

Prior authorization must be obtained from the BCBSRI Pharmacy Benefit Management vendor (covermymeds.com) or by contacting the PBM at 1-800-693-6651 (fax 855-212-8110) prior to claim submission for non-OneTouch branded devices.

Covered HCPCS when criteria met: The following HCPCS codes are covered when medical criteria and prior authorization requirements are satisfied: A4253, A4259, E0607, E2100, E2101. Claims must include HCPCS and the NDC for the device dispensed.

Rental & Purchase Rules

Rule	Details
Rental/purchase rules	No rental or purchase rules specified in the policy document.
Implication for providers	Because the document does not specify rental or purchase rules, standard billing and benefit booklet provisions apply; refer to the member's Benefit Booklet or Evidence of Coverage for contract-specific DME purchase/rental terms.

Replacement

Replacement rules statedNot specified in the document.

Claims filing noteIf replacement items are requested, claims must be filed with HCPCS and NDC for the device dispensed as required elsewhere in the policy.

Prior authorization implicationReplacement of non-OneTouch branded devices would follow the same prior authorization requirements as initial requests (PBM/covermymeds.com).

Documentation and Claims

Documentation Required

Include HCPCS and NDC on claims; obtain prior authorization via covermymeds.com or PBM

Claims must be filed with the HCPCS and NDC for the device dispensed, and prior authorization for non-OneTouch products must be obtained through covermymeds.com or by contacting the BCBSRI PBM vendor. Include HCPCS/NDC on the claim and retain prior authorization documentation as part of the submission.

Ensure HCPCS and NDC appear on all claims for the device
Obtain prior authorization via covermymeds.com or PBM contact and keep documentation for claim support

Not Covered

Under the Medicare Advantage limited benefit, OneTouch products are the preferred covered brand (examples listed in the policy include OneTouch Verio and OneTouch Ultra series). Non-OneTouch brands, including test strips, are only covered for Medicare Advantage members when the policy's coverage criteria and prior authorization requirements are met; otherwise OneTouch remains the default covered brand.