CurrentFidelis CarePolicy N/A

Download?Clientdocumentid=8Lj6Ynjja0Yznrfhz6I4_Q

List of preferred blood glucose meters, test strips, CGM devices and associated National Reimbursement Codes (NRC) with formulary restrictions (quantity limits and prior authorization) for in-network pharmacy coverage; includes contact instructions for prior authorization and member services.

Policy Summary

PayerFidelis Care

PolicyDownload?Clientdocumentid=8Lj6Ynjja0Yznrfhz6I4_Q

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionObtain prior authorization for listed Dexcom and FreeStyle Libre CGM devices/sensors/receivers and contact Member Services to request prior authorization.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this update.

5Preferred meters listed

9Preferred test strip SKUs listed

11CGM SKUs requiring PA

1Member Services contact

Policy overview

This list identifies the preferred blood glucose monitoring products you can receive from an in-network pharmacy and includes the National Reimbursement Code (NRC) to help accurately identify covered products. Formulary restrictions such as Quantity Limits (for example, 1 kit per 365 days for meters and 4 strips per day for test strips) and Prior Authorization may apply. All lancets and lancing devices by any manufacturer are covered.

Key metadata

Scope summaryList of preferred blood glucose meters, test strips, CGM devices and associated National Reimbursement Codes (NRC) with formulary restrictions (quantity limits and prior authorization) for in-network pharmacy coverage; includes contact instructions for prior authorization and member services.

Coverage stancemixed

StatusCURRENT

SubjectCovered diabetes blood glucose meters, test strips, CGM devices and supply restrictions

Member Services contactCall Member Services at 1-800-247-1447 (TTY: 711) for benefit questions and to request prior authorization; specific phone hours vary by date range.

National Reimbursement Codes (NRC) — covered products

Covered continuous glucose monitoring (CGM) devices/transmitters/sensors (preferred but PA required)mixedCovered

08627-0091-11	Dexcom G6 Receiver
08627-0016-01	Dexcom G6 Transmitter
08627-0053-03	Dexcom G6 Sensor
08627-0078-01	Dexcom G7 Receiver
08627-0077-01	Dexcom G7 Sensor
57599-0803-00	FreeStyle Libre 2 Reader
57599-0835-00	FreeStyle Libre 2 Plus Sensor
57599-0820-00	FreeStyle Libre 3 Reader
57599-0844-00	FreeStyle Libre 3 Plus Sensor
57599-0002-00	FreeStyle Libre 14 Day Reader

1–10 of 11

1/2

The NRC is used to identify covered products and the plan’s formulary restrictions (such as quantity limits and prior authorization requirements) may apply to specific items. Lancets and lancing devices are covered regardless of manufacturer.

Billing, prior authorization, and dispensing requirements

Prior Authorization

Prior authorization required for CGM devices/sensors/receivers

Obtain prior authorization for any Dexcom G6/G7 devices and FreeStyle Libre readers/sensors listed (PA required per product). Contact Member Services to request prior authorization.

08627-0091-11
08627-0016-01
08627-0053-03
08627-0078-01
08627-0077-01
57599-0803-00
57599-0835-00
57599-0820-00
57599-0844-00
57599-0002-00
57599-0001-01
Contact Member Services to request prior authorization

Billing Rule

Adhere to specified quantity limits for meters and test strips

Dispense meters and test strips according to the plan's quantity limits. Meters are limited to 1 kit per 365 days (1 per calendar year) where specified. Test strips are limited to 4 strips per day (example: 100 strips per 25 days).

65702-0729-10
65702-0731-10
56151-1470-02
56151-1490-02
56151-1491-02
65702-0701-95
65702-0711-10
65702-0719-10
65702-0712-10
56151-1460-03
56151-1460-04
56151-1460-01
56151-1461-04
56151-1461-01
Meter limit: 1 kit per 365 days; Test strip limit: 4 strips per day (e.g., 100 strips per 25 days)

Prior Authorization

Non-preferred supplies require prior authorization or new prescription

For non-preferred diabetic testing supplies, obtain a new prescription or request prior authorization for a non-preferred blood glucose monitor and test strips.

Documentation Required

Member/Provider contact for PA and benefits

Call Member Services at 1-800-247-1447 (TTY: 711) for benefit questions and to request prior authorization; specific phone hours vary by date range.