CurrentLouisiana Department of HealthPolicy N/A

Louisiana Medicaid Diabetic Supplies List

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Coverage criteria and pharmacy claim requirements for diabetic supplies reimbursed by Louisiana Medicaid Fee-for-Service and participating Managed Care Organizations, including glucose monitors, meters, strips, lancets, insulin delivery supplies, and related equipment.

Policy Summary

PayerLouisiana Department of Health

PolicyLouisiana Medicaid Diabetic Supplies List

Policy CodePolicy N/A

Change TypeRevised — no material clinical or coverage changes

Effective DateOctober 1, 2025

Next Review DateN/A

Key ActionUse the Louisiana Uniform Prescription Drug Prior Authorization Form to request clinical authorization for CGM devices.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

6 monthsCGM authorization period

180 daysInsulin-claim lookback

1/yearBlood glucose meter limit

200/204 per 30 daysTest strips/lancets with insulin use

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CurrentLouisiana Department of HealthPolicy N/A

Louisiana Medicaid Diabetic Supplies List

Customize your policy alerts

Sign up for all Louisiana Department of Health policy alerts

Know when Louisiana Department of Health releases new policies or updates existing guidance.

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Receive email alerts as soon as relevant payer policies are published or updated.

Policy Summary

PayerLouisiana Department of Health

PolicyLouisiana Medicaid Diabetic Supplies List

Policy CodePolicy N/A

Change TypeRevised — no material clinical or coverage changes

Effective DateOctober 1, 2025

Next Review DateN/A

Key ActionUse the Louisiana Uniform Prescription Drug Prior Authorization Form to request clinical authorization for CGM devices.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

6 monthsCGM authorization period

180 daysInsulin-claim lookback

1/yearBlood glucose meter limit

200/204 per 30 daysTest strips/lancets with insulin use

Test strips/lancets without insulin use

Coverage Criteria

CGM initiation therapy

Covered for initiation when all applicable requirements below are met:

Initiation requirements

ONE qualifying clinical condition
- The recipient has a diagnosis of diabetes of any type with evidence of at least one pharmacy claim for insulin within the previous 180-day period.At least 1 insulin claim within 180 days
- There is evidence of level 2 (moderate) or level 3 (severe) hypoglycemia.
- The recipient has glycogen storage disease type 1a.
Preferred-device pathway or ONE non-preferred-device exception
- The requested continuous glucose monitor is preferred.
- ONE non-preferred CGM exception
  - The recipient is continuing use of a non-preferred continuous glucose monitor.
  - The recipient has had a trial of and inadequate response or intolerance to one preferred continuous glucose monitor.
    Device samples, coupons, and discount cards do not count as a trial.
  - The recipient has limitations of use to the preferred continuous glucose monitor(s).
  - The recipient is utilizing an insulin pump that is only compatible with a non-preferred continuous glucose monitor.

CGM continuation therapy

Covered for continuation when all of the following are met:

Continuation requirement

The prescriber states on the request that the recipient attended a follow-up visit with a healthcare provider to assess the ongoing benefits.One documented follow-up visit
Approval for initiation or continuation of therapy is for 6 months.

Device samples, coupons, and discount cards do not count as a qualifying preferred-CGM trial. When requesting a non-preferred continuous glucose monitor, document an eligible trial and inadequate response or intolerance, or another applicable exception identified in the policy.

CGM Medical Necessity

CGM medical necessity

CGM is medically necessary when at least one of the following clinical indications is documented:

ONE clinical indication

The recipient has diabetes with evidence of at least one pharmacy claim for insulin within the previous 180-day period.At least 1 insulin claim within 180 days
The recipient has level 2 or level 3 hypoglycemia.
The recipient has glycogen storage disease type 1a.

Covered Products and Coding Rules

Continuous glucose monitors and receiversNDCCovered

08627005303	Guardian 4 glucose sensor
08627001601	Dexcom G6 transmitter
63000044515	Dexcom G7 15 day sensor
08627007901	Dexcom G7 15 day sensor
08627007801	Dexcom G7 receiver
43169095568	Dexcom G7 receiver
08627007701	Dexcom G7 sensor
63000028678	Dexcom G7 sensor
57599000101	FreeStyle Libre 14 day sensor
63000031699	FreeStyle Libre 2 Plus sensor

1–10 of 21

1/3

Preferred blood glucose metersNDCCovered

00193755301	Contour Next EZ meter system
00193792201	Contour Next GEN meter
00193782501	Contour Next One meter
00193703601	Contour Plus Blue meter
57599881401	Precision Xtra monitor
56151149102	ReliOn True Metrix Air glucose meter
56151149002	True Metrix Air glucose meter
56151147002	True Metrix blood glucose meter

Preferred blood glucose test stripsNDCCovered

00193731025	Contour Next test strip
00193731150	Contour Next test strip
00193731221	Contour Next test strip
56151146003	True Metrix glucose test strip
56151146004	True Metrix glucose test strip
56151146101	ReliOn True Metrix test strip
56151146104	ReliOn True Metrix test strip
56151146304	True Metrix glucose test strip

Blood glucose control solutionNDCCovered

56151145001	True Metrix level 1 control solution
56151145002	True Metrix level 2 control solution
56151145003	True Metrix level 3 control solution

External insulin pumps and pump suppliesNDCCovered

73108000008	CeQur Simplicity 2U 4-day patch
73108000100	CeQur Simplicity inserter
50050010115	iLet infusion/contact detach 23 inch 6 mm
50050010120	iLet infusion/contact detach 23 inch 6 mm
50050010010	iLet infusion kit/inset 23 inch 6 mm
50050010015	iLet infusion kit/inset 23 inch 6 mm
50050010210	iLet infusion kit/inset 32 inch 6 mm
50050010215	iLet infusion kit/inset 32 inch 6 mm
50050000401	iLet starter kit contact 23 inch 6 mm
50050000201	iLet starter kit/inset 23 inch 6 mm

1–10 of 16

1/2

Ketone strips, lancets, and lancing devicesNDCCovered

57599074501	Precision Xtra blood ketone strip
56151060150	TruePlus ketone test strip
00193660601	Microlet 2 lancing device
00193654621	Microlet lancets
00193658621	Microlet lancets
00193670201	Microlet Next lancing device
56151014201	TrueDraw lancing device
56151014701	TruePlus 33G lancets
56151034101	TruePlus safety 28G lancet
56151034125	TruePlus safety 28G lancet

1–10 of 12

1/2

Preferred pen needlesNDCCovered

08290320550	BD Nano 2 Gen pen needle 32G 4 mm
08290320749	BD UF Micro pen needle 6 mm x 32G
08290320119	BD UF Mini pen needle 5 mm x 31G
08290320122	BD UF Nano pen needle 4 mm x 32G
08290328203	BD UF Original pen needle 12.7 mm x 29G
08290320109	BD UF Short pen needle 8 mm x 31G
83017055003	Nano 2 Gen pen needle 32G 4 mm
83017012203	Nano pen needle 32G 4 mm
08470342901	Pentips pen needle 29G 1/2 inch
08470349001	Pentips pen needle 31G 1/4 inch

1–10 of 28

1/3

Preferred insulin syringesNDCCovered

10118089032	AQ insulin syringe 0.5 mL 30G 8 mm
10118089040	AQ insulin syringe 1 mL 31G 8 mm
10118089036	AQ insulin syringe 1 mL 29G 12 mm
08290328440	BD insulin syringe 0.3 mL 8 mm x 31G
08290326730	BD insulin syringe U-500 1/2 mL 6 mm x 31G
08290328431	BD UF insulin syringe 0.3 mL 12.7 mm x 30G
08290328466	BD UF insulin syringe 0.5 mL 12.7 mm x 30G
08290328411	BD UF insulin syringe 1 mL 30G 12.7 mm
08290328438	BD UF insulin syringe 0.3 mL 8 mm x 31G
08290328468	BD UF insulin syringe 0.5 mL 8 mm x 31G

1–10 of 60

1/6

Preferred lancets and devices POS editsNDC

08496285501 = 08496285511	EASY TOUCH INSULIN SYR 0.5 ML
08496285501 = 08496295501	EASY TOUCH INSULIN SYR 0.5 ML
08496285501 = 08496305601	EASY TOUCH INSULIN SYR 0.5 ML
08496285501 = 08496315601	EASY TOUCH INSULIN SYR 0.5 ML
08496285501 = 08496281501	EASY TOUCH INSULIN SYR 1 ML
08496285501 = 08496291501	EASY TOUCH INSULIN SYR 1 ML
08496285501 = 08496651001	EASY TOUCH SYR 1 ML 27G 12.7MM
08496285501 = 08496702001	EASY TOUCH SYR 1 ML 27G 16MM
08496285501 = 08496651101	EASY TOUCH SYR 1 ML 28G 12.7MM
08496285501 = 08496651201	EASY TOUCH SYR 1 ML 29G 12.7MM

Preferred lancets and devices POS editsNDC

08496311601 = 38396041340	EQL INS SYR 1 ML 29GX1/2"
08496311601 = 38396041940	EQL INSUL SYR 0.3 ML 31GX5/16"
08496311601 = 38396042040	EQL INSUL SYR 0.5 ML 31GX5/16"
08496311601 = 38396041140	EQL INSULIN 0.3 ML SYRINGE
08496311601 = 38396041440	EQL INSULIN 0.3 ML SYRINGE
08496311601 = 38396041240	EQL INSULIN 0.5 ML SYRINGE
08496311601 = 38396041540	EQL INSULIN 0.5 ML SYRINGE
08496311601 = 38396041640	EQL INSULIN 1 ML SYRINGE
08496311601 = 38396042140	EQL INSULIN SYR 1 ML 31GX5/16"
08496311601 = 08287126027	EXEL INS SYR U100 1 ML 28GX1/2

1–10 of 15

1/2

Preferred lancets and devices POS editsNDC

08287126029 = 20221026029	EXEL U100 INS SYR 1 ML 29GX1/2
08287126029 = 38396044564	GNP INS SYR 0.3 ML 29GX1/2"
08287126029 = 87701042608	GNP INSUL SYRINGE 1 ML 28G 1/2"
08287126029 = 38396044964	GNP INSUL SYR 0.3 ML 31GX5/16"
08287126029 = 38396045064	GNP INSUL SYR 0.5 ML 31GX5/16"
08287126029 = 87701039972	GNP INSUL SYR 0.5 ML 31GX5/16"
08287126029 = 87701042616	GNP INSUL SYR 0.5 ML 31GX5/16"
08287126029 = 38396045164	GNP INSULIN SYR 1 ML 31GX5/16"
08287126029 = 87701039973	GNP INSULIN SYR 1 ML 31GX5/16"
08287126029 = 83017673003	INS SYR U-500 0.5 ML 31G 6MM

1–10 of 88

1/9

Preferred lancets and devices POS editsNDC

38396000506 = 38396000606	KINRAY SYRING 0.5 ML 31GX5/16"
38396000506 = 38396040325	KMART VALU PLUS SYR 1/2 ML
38396000506 = 38396040725	KMART VALU PLUS SYR 1/2 ML
38396000506 = 38396040218	KRO INS SYR 0.3 ML 29GX1/2"
38396000506 = 41260038507	KRO INS SYRIN 0.3 ML 30GX5/16"
38396000506 = 41260038510	KRO INS SYRIN 0.3 ML 31GX5/16"
38396000506 = 41260038508	KRO INS SYRIN 0.5 ML 30GX5/16"
38396000506 = 38396041018	KRO INS SYRIN 0.5 ML 31GX5/16"
38396000506 = 41260038511	KRO INS SYRIN 0.5 ML 31GX5/16"
38396000506 = 41260038523	KRO INS SYRING 0.5 ML 29GX1/2"

1–10 of 129

1/13

Preferred CGM clinical authorization bypass

Applies toPreferred continuous glucose-monitoring devices

Required evidenceAt least one pharmacy claim for insulin

Lookback periodWithin the previous 180 days

Blood glucose meter quantity limit

Equipment

Provider Actions and Claim Requirements

Prior Authorization

CGM Authorization and Pharmacy Claims

Use the Louisiana Uniform Prescription Drug Prior Authorization Form to request clinical authorization for continuous glucose-monitoring (CGM) devices. Pharmacy claims for a preferred CGM bypass clinical authorization when there is evidence of at least one insulin pharmacy claim within the previous 180 days; CGM quantity limits still apply.

Note

Six-Month Approval Period

Authorization for CGM initiation or continuation is issued for 6 months.

Step Therapy

Preferred CGM Trial or Exception

For a non-preferred CGM, document at least one qualifying exception: the recipient is continuing use of a non-preferred CGM; has tried one preferred CGM and had an inadequate response or intolerance; has limitations of use with the preferred CGM(s); or uses an insulin pump compatible only with a non-preferred CGM. Device samples, coupons, and discount cards do not count as a trial.

Policy Background

The Louisiana Medicaid Diabetic Supplies List supports diabetes self-management and insulin administration through glucose monitoring, continuous glucose monitoring, insulin delivery, and related supplies. The list also establishes preferred-product requirements, diagnosis-based quantity edits, and clinical authorization requirements for continuous glucose monitors.

Definitions

Level 2 or level 3 hypoglycemia

Definition categoryHypoglycemia events are classified as level 2 or level 3

Level 2Moderate hypoglycemia

Level 3Severe hypoglycemia

Preferred and non-preferred CGM

Preferred CGMA continuous glucose-monitoring product identified by the program as preferred

Non-preferred CGMRequires documentation of an applicable clinical exception for approval

Examples of exceptionsContinuing a non-preferred device; inadequate response or intolerance after a qualifying preferred-CGM trial; limitations of preferred CGM use; or an insulin pump compatible only with a non-preferred CGM

Replacement Limits

Blood glucose meter replacement

EquipmentBlood glucose meters

Replacement quantity1 meter

Replacement intervalPer year

Required Documentation

Documentation Required

Complete the CGM authorization form

Use the Louisiana Uniform Prescription Drug Prior Authorization Form for CGM clinical authorization. State the qualifying clinical condition and, for a non-preferred CGM, document the applicable continuation, trial or intolerance, limitation, or insulin-pump compatibility rationale.

Documentation Required

Confirm follow-up for continuation therapy

For continuation therapy, the prescriber must state that the recipient attended a follow-up visit with a healthcare provider to assess ongoing benefit.

Policy Summary

PayerLouisiana Department of Health

PolicyLouisiana Medicaid Diabetic Supplies List

Policy CodePolicy N/A

Change TypeRevised — no material clinical or coverage changes

Effective DateOctober 1, 2025

Next Review DateN/A

Key ActionUse the Louisiana Uniform Prescription Drug Prior Authorization Form to request clinical authorization for CGM devices.

SourceLink

On This Page

Blood glucose meters

Quantity limit1 meter

Limit periodPer year

Test strips and lancets with insulin use

Applies whenGestational diabetes, diabetes in pregnancy, or diabetes with insulin use

Quantity limit200/204 test strips per 30 days

Package directionUse the preferred package size and dispense up to the quantity limit based on directions

Test strips and lancets without insulin use

Applies whenDiabetes without insulin use

Quantity limit100/102 test strips every 90 days

Package directionUse the preferred package size and dispense up to the quantity limit based on directions

Documentation Required

CGM Form and Clinical Documentation

Submit the Louisiana Uniform Prescription Drug Prior Authorization Form and state the clinical information supporting the request, including the applicable initiation criteria and any required non-preferred CGM documentation.

Documentation Required

Continuation Documentation

For continuation of therapy, the prescriber must state that the recipient attended a follow-up visit with a healthcare provider to assess ongoing benefits.

Billing Rule

Diagnosis Coding for Pharmacy Claims

Submit an appropriate diagnosis code with pharmacy claims for blood glucose test strips and lancets. The diagnosis code determines the applicable quantity limit.

Denial Risk

Insufficient Non-Preferred CGM Rationale

A non-preferred CGM request may be denied when the required continuation, preferred-device trial with inadequate response or intolerance, preferred-device limitation, or insulin-pump compatibility rationale is not adequately documented.

Denial Risk

Initiation Criteria Not Met

CGM initiation is not approvable unless the request states one qualifying condition: diabetes of any type with at least one insulin pharmacy claim in the previous 180 days; level 2 or level 3 hypoglycemia; or glycogen storage disease type 1a. Non-preferred CGM requests must also meet a qualifying exception.

Denial Risk

Follow-Up Assessment Not Documented

Continuation may be denied when the prescriber does not document a follow-up visit assessing the recipient’s ongoing benefit from therapy.

Billing Rule

Diagnosis or Quantity-Limit Edit

A pharmacy claim for test strips or lancets may reject when it lacks an appropriate diagnosis code or exceeds the quantity limit associated with the submitted diagnosis.

Gestational diabetes, diabetes in pregnancy, or diabetes with insulin use: 200/204 strips or lancets per 30 days.
Diabetes without insulin use: 100/102 strips or lancets every 90 days.
Use the preferred package size and dispense up to the applicable limit based on directions.

Trial exclusionDevice samples, coupons, and discount cards do not count as a qualifying preferred-CGM trial