Glucose Monitoring - Home - Non-OneTouch Brand
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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.
No material clinical or coverage changes in this revision.
Coverage Criteria
Coverage criteria for non-OneTouch branded devices
Covered when ALL of the following 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
Provider Actions and 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.
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.
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.
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
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:
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
Documentation and Claims
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.
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