Diabetic Blood Glucose Test Strips and Cartridges Prior Authorization
Customize your policy alerts
Sign up for all Capital Bluecross policy alerts
Know when Capital Bluecross releases new policies or updates existing guidance.
Monitor payer policy activity
This document governs prior authorization review for diabetic testing supplies (blood glucose test strips and cartridges) when a requested amount exceeds the program benefit limit. It affects prescribers, pharmacists, and members covered by Capital Bluecross in the specified jurisdiction.
No material clinical or coverage changes in this revision.
Coverage Criteria
Authorization when request exceeds benefit limit
Covered when ALL of the following are met
Approval length shall be determined based upon the prescriber's anticipated course of therapy, unless superseded by other source limits.
Automatic approval within benefit limit
Coverage for diabetic blood glucose test strips and cartridges is governed by the program benefit limit. Requests at or below the benefit limit of 102 units per 30 days are approved. When the amount requested is greater than the program benefit limit, the request may be covered only if the prescriber submits supporting documentation demonstrating medical need for a higher quantity and a pharmacist reviews and approves based on that documentation.
Requests that exceed the program benefit limit are not approved unless the prescriber has submitted documentation supporting therapy with a higher amount for the intended diagnosis. If such documentation is not provided, the request will be denied.
Coding and Limits
| 94100030006100 | GPI for Blood Glucose Test Strips |
| 94100030006020 | GPI for Blood Glucose Test Cartridges |
Provider Actions and Requirements
Prior authorization required when request exceeds 102 units/30 days
Prior authorization is required when the amount requested exceeds the program benefit limit of 102 units per 30 days; the prescriber must submit supporting documentation for higher amounts for pharmacist review and possible approval.
- Applies to GPIs 94100030006100 (test strips) and 94100030006020 (cartridges).
Provider action: follow the two-step prior authorization question set
If the amount requested is not greater than the program benefit limit, the request should be approved; if it is greater, follow the two-step prior authorization question set in the policy.
- Question 1 of the Prior Authorization Criteria: determine whether the requested amount is greater than the program benefit limit (102/30 days).
- Question 2: if greater, verify prescriber-submitted documentation supports the higher amount and have pharmacist review.
Prescriber must submit supporting documentation for higher amounts
The prescriber must submit documentation supporting therapy with a higher amount for the intended diagnosis when the requested amount exceeds the program benefit limit; the pharmacist will review the information and may approve based on that review.
- Documentation must support need for quantity > 102 units per 30 days.
- Length of approval is based on the prescriber's anticipated course of therapy unless superseded by another source limit.
Denial if no supporting documentation for amounts over benefit limit
A request will be denied if the amount requested is greater than the program benefit limit (102 units per 30 days) and the prescriber has not submitted documentation supporting therapy with a higher amount for the intended diagnosis.
- Denial occurs when Question 2 is answered 'No' (no supporting documentation provided).
Background
Blood glucose test strips and cartridges are supplies used for self-monitoring of blood glucose in patients with diabetes. Coverage and quantity limits—such as the benefit limit of 102 units per 30 days—are applied to manage supply utilization and ensure appropriate use. When prescribers request quantities above the limit, they must submit clinical documentation supporting the higher amount so the pharmacist can review and determine whether to approve for the member’s intended course of therapy.
Definitions
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.