CurrentFidelis CarePolicy N/A

Covered Diabetes Meters and Testing Supplies

Lists preferred blood glucose meters, test strips, lancets, and continuous glucose monitoring (CGM) products available through Fidelis Care in-network pharmacies, including NRC identifiers and formulary restrictions; affects members covered by Fidelis Care.

Policy Summary

PayerFidelis Care

PolicyCovered Diabetes Meters and Testing Supplies

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization for listed CGM receivers, transmitters, and sensors before coverage; contact Member Services at 1-800-247-1447 to request authorization.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

≥10listed meters, strips, and CGM items

1/365dmeter kit quantity limit

4/daytest strip daily limit

RequiredCGM prior auth

All coveredlancet coverage

Coverage Criteria

Covered with formulary restrictions and prior authorization

Covered when criteria below are met or when items are preferred on the formulary with required authorizations:

Preferred supplies: Item is listed as a preferred product in the formulary (meter, strip, lancet, or CGM item) with corresponding NRC

Examples: Accu-Chek meters and strips; True Metrix; Relion; Dexcom; FreeStyle Libre

Quantity limits for meters: Meter kits are subject to a quantity limit of 1 kit per 365 days (1 per calendar year)1 kit / 365 days

Applies to meters listed in chunk 1

Quantity limits for test strips: Test strips are subject to a quantity limit of 4 strips per day (e.g., 100 strips per 25 days)

Policy Summary

PayerFidelis Care

PolicyCovered Diabetes Meters and Testing Supplies

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization for listed CGM receivers, transmitters, and sensors before coverage; contact Member Services at 1-800-247-1447 to request authorization.

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.

Covered Devices, Supplies, and Coding

Covered blood glucose metersNRCCovered

65702-0729-10	Accu-Chek Guide Meter
65702-0731-10	Accu-Chek Guide Me Meter
56151-1470-02	True Metrix Meter
56151-1490-02	True Metrix Air Meter
56151-1491-02	Relion True Metrix Air Meter

Covered test stripsNRCCovered

65702-0701-95	Accu-Chek Guide Test Strips (50-count)
65702-0711-10	Accu-Chek Guide Test Strips (50-count)
65702-0719-10	Accu-Chek Guide Test Strips (50-count)
65702-0712-10	Accu-Chek Guide Test Strips (100-count)
56151-1460-03	True Metrix Test Strips (25-count)
56151-1460-04	True Metrix Test Strips (50-count)
56151-1460-01	True Metrix Test Strips (100-count)
56151-1461-04	Relion True Metrix Test Strips (50-count)
56151-1461-01	Relion True Metrix Test Strips (100-count)

CGM devices and sensorsNRCCovered

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

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Quantity limits — meters and test strips

Meter kits quantity limit1 kit per 365 days (1 per calendar year)

Test strips daily limit4 strips per day (example: 100 strips per 25 days)

Applies to listed metersQuantity limits apply to Accu-Chek and True Metrix meters listed with NRCs

Provider Actions and Prior Authorization

Prior Authorization

Prior Authorization Required for CGM

Prior authorization is required for Continuous Glucose Monitoring (CGM) devices, including receivers, transmitters, and sensors (e.g., Dexcom G6/G7, FreeStyle Libre family). Ensure a PA is obtained before ordering or dispensing these items to avoid denial of coverage.

Affected products: Dexcom G6/G7 receivers, transmitters, and sensors; FreeStyle Libre readers and sensors (14-day, Libre 2, Libre 3, Libre 2 Plus/3 Plus).
Action: Contact Member Services to request prior authorization before dispensing/ordering CGM supplies.

Billing Rule

Formulary Restrictions for Meters and Strips

Preferred blood glucose meters and test strips have quantity limits; non-preferred items may require prior authorization. If a member uses non-preferred testing supplies, the provider should submit a new prescription for a preferred product or request prior authorization for the non-preferred item.

Meters: Typical limit = 1 kit per 365 days (examples: Accu-Chek Guide, Accu-Chek Guide Me, True Metrix, True Metrix Air).
Test strips: Typical limit = 4 strips per day (e.g., ~100 strips per 25 days for listed pack sizes).
If supplies are not preferred, submit PA requests or prescribe a preferred alternative to align with formulary restrictions.

Note

Prior Authorization Contact & Hours

To request prior authorization or for benefit questions, contact Member Services at 1-800-247-1447 (TTY: 711). Hours: October 1–March 31: 7 days/week, 8 a.m.–8 p.m.; April 1–September 30: Monday–Friday, 8 a.m.–8 p.m. After hours, weekends, and federal holidays use the messaging system.

Use Member Services number to initiate PA requests for CGM and non-preferred meters/strips.
Messaging system available after hours, weekends, and federal holidays.

Prior Authorization

Prior Authorization Required for Dexcom and FreeStyle Libre

Emphasize that prior authorization applies specifically to Dexcom and FreeStyle Libre products (receivers/readers, transmitters, and sensors). Obtain PA before provision to prevent claim denials.

PA requirement covers all related components: receivers/readers, transmitters, and sensors.
Confirm PA approval status with Member Services prior to dispensing.

Definitions

Lancets and lancing devices — coverage

Coverage statementAll lancets and lancing devices by any manufacturer are covered by the plan.

Source guidanceLancet coverage noted with preferred product list for in-network pharmacies

No quantity or prior auth notedSource does not list separate quantity limits or prior authorization for lancets/lancing devices

Continuous Glucose Monitoring (CGM) — definition and prior authorization

Definition of CGM systemsContinuous Glucose Monitoring (CGM) systems include receivers, transmitters, and sensors (examples listed: Dexcom G6/G7; FreeStyle Libre readers and sensors).

Prior authorization requirementPrior authorization is required for listed CGM receivers, transmitters, and sensors (Dexcom G6/G7 and FreeStyle Libre variants).

Covered CGM NRCsExamples of covered CGM NRCs include Dexcom (08627-0091-11, 08627-0016-01, 08627-0053-03, 08627-0078-01, 08627-0077-01) and FreeStyle Libre (57599-0803-00, 57599-0835-00, 57599-0820-00, 57599-0844-00, 57599-0002-00, 57599-0001-01).

OpenPayer

Covered Diabetes Meters and Testing Supplies

Coverage Criteria

Covered Devices, Supplies, and Coding

Provider Actions and Prior Authorization

Background

Definitions