CurrentCentenePolicy HIM.PA.34

Clinical Policy: Non-Formulary Test Strips

Defines medical necessity and prior authorization requirements for non-formulary blood glucose test strips for members receiving benefits through Centene-affiliated health plans. Applies to providers requesting coverage of non-formulary glucose test strips.

Policy Summary

PayerCentene

PolicyNon-Formulary Test Strips

Policy CodePolicy HIM.PA.34

Change TypeNo material changes

Effective DateFeb 1, 2016

Next Review Date

Key ActionSubmit prior authorization with supporting clinical documentation and a letter of medical necessity explaining why formulary strips cannot be used.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

12 monthsapproval duration

Prior authauthorization

Diabetesindication

Requireddocumentation

Coverage Criteria for Non‑Formulary Blood Glucose Test Strips

Initial Approval — Non-formulary blood glucose test strips

Non-formulary blood glucose test strips are medically necessary when ALL of the following are met:

Initial requirements: Provider submits documentation supporting that member has met all approval criteria (such as office chart notes, lab results, or other clinical information) and provides a letter of medical necessity detailing why current formulary products cannot be used (e.g., dexterity impairment, use of an insulin pump requiring specific test strips).

Approval duration: 12 months

Member status: Member either (a) is currently receiving the prescribed product via Centene benefit or has previously met initial approval criteria, OR (b) is currently receiving the prescribed product and is enrolled in a state and product with continuity of care regulations.

Approval duration: 12 months

Other diagnoses/indications: Not applicable.

Diagnoses/Indications for which coverage is NOT authorized: Not applicable.

Policy Summary

PayerCentene

PolicyNon-Formulary Test Strips

Policy CodePolicy HIM.PA.34

Change TypeNo material changes

Effective DateFeb 1, 2016

Next Review Date

Key ActionSubmit prior authorization with supporting clinical documentation and a letter of medical necessity explaining why formulary strips cannot be used.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Provider Requirements and Prior Authorization

Prior Authorization

Prior Authorization Required

Prior authorization is required for non-formulary blood glucose test strips. Requests must include a letter of medical necessity explaining why formulary products cannot be used (for example, dexterity impairment or use of an insulin pump requiring specific strips). Approval duration: 12 months.

Approval duration: 12 months
Include Letter of Medical Necessity

Documentation Required

Required Documentation

Provider must submit documentation (such as office chart notes, lab results, or other clinical information) supporting that the member has met all approval criteria. Failure to submit sufficient documentation may result in denial of the request.

Examples of acceptable documentation: office chart notes, lab results, device documentation
Failure to provide supporting documentation may result in denial

Step Therapy

Step Therapy / Formulary Trial

Provider must submit a letter of medical necessity stating why formulary products cannot be used (e.g., dexterity impairment, use of an insulin pump requiring specific test strips). If the member is currently receiving the prescribed non-formulary product via the Centene benefit or previously met initial approval criteria, include documentation of prior use. Continuity of care may apply per state-specific addendums for CC.PHARM.03A and CC.PHARM.03B.

State-specific continuity of care may apply — see CC.PHARM.03A and CC.PHARM.03B
Document prior use if member is currently receiving the non-formulary product

Background

Blood glucose test strips are consumable devices used with blood glucose meters to measure and monitor blood glucose levels in patients with diabetes mellitus. This policy applies to requests for non-formulary blood glucose test strips and requires clinical justification when the prescribed strip is not on the plan’s formulary.

For non-formulary requests, the provider must submit documentation supporting that the member meets the approval criteria and a letter of medical necessity explaining why formulary products cannot be used (examples include dexterity impairment or the need for strips compatible with an insulin pump). Failure to provide required clinical documentation may result in denial.

Prior authorization is required for non-formulary blood glucose test strips. If approved, authorization is granted for 12 months.

The policy’s clinical context aligns with the FDA-approved indication: blood glucose test strips are intended to monitor blood glucose levels in patients with diabetes mellitus.

OpenPayer

Clinical Policy: Non-Formulary Test Strips

Coverage Criteria for Non‑Formulary Blood Glucose Test Strips

Provider Requirements and Prior Authorization

Definitions

Background