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    v1.0.30
    OpenPayerPolicy UpdatesReimbursement/Payment PolicyLouisiana Medicaid Diabetic Supply Coverage | Open…
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    CurrentLouisiana Department of HealthPolicy N/A

    Louisiana Medicaid Diabetic Supplies List

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    This document lists diabetic supplies reimbursed by the Louisiana Medicaid Fee-for-Service Pharmacy Program and participating Managed Care Organizations. It governs pharmacy reimbursement, prior authorization, preferred-product requirements, quantity limits, and point-of-sale edits for Medicaid recipients.

    Policy Summary
    PayerLouisiana Department of Health
    PolicyLouisiana Medicaid Diabetic Supplies List
    Policy CodePolicy N/A
    Change TypeNo material change
    Effective DateOct 1, 2025
    Next Review DateN/A
    Key ActionUse the Louisiana Uniform Prescription Drug Prior Authorization Form to request clinical authorization for continuous glucose-monitoring devices.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    6 monthsCGM approval duration
    180 daysInsulin claim lookback
    1/yearBlood glucose meter limit
    200/204 per 30 daysTest strips and lancets with insulin use

    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.

    100/102 per 90 days
    Test strips and lancets without insulin use
    6 MCOs + FFSParticipating Medicaid entities

    Coverage Criteria

    CGM Initiation and Non-Preferred Product Criteria

    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 the clinical authorization requirement when there is evidence of at least one pharmacy claim for insulin within the previous 180 days. CGM products are subject to the applicable quantity limits.

    ALL of the following

    • ONE of the following initiation criteria

      • The recipient has a diagnosis of diabetes of any type with evidence of at least one pharmacy claim for insulin within the previous 180 days. The diagnosis and evidence must be stated on the request.
      • The recipient has documented level 2 (moderate) or level 3 (severe) hypoglycemia. The documentation must be stated on the request.
      • The recipient has glycogen storage disease type 1a. The diagnosis must be stated on the request.

    • If the request is for a non-preferred CGM, ONE of the following is required

      • The recipient is continuing use of a non-preferred CGM. This must be documented on the request.
      • The recipient has had a trial of one preferred CGM with inadequate response or intolerance. Device samples, coupons, and discount cards do not qualify as a trial.
      • The recipient has limitations of use to the preferred CGM(s). This must be documented on the request.
      • The recipient is utilizing an insulin pump that is only compatible with a non-preferred CGM. This must be documented on the request.

    CGM Continuation Criterion

    Continuation approval requires documentation on the request; initiation or continuation approval is granted for 6 months.

    ALL of the following

    • The prescriber states on the request that the recipient has attended a follow-up visit with a healthcare provider to assess the ongoing benefits of CGM.
    • The requested continuation period does not exceed the 6-month approval duration.<= 6 months

    Test Strip and Lancet Point-of-Sale Criteria

    Pharmacy claims for preferred blood glucose test strips and lancets must include an appropriate diagnosis code from the applicable Louisiana Medicaid diagnosis-code list. Quantity limits are determined by the diagnosis code submitted on the pharmacy claim. Use the preferred package size and dispense up to the quantity limit based on directions.

    ALL of the following point-of-sale requirements

    • Blood glucose test strip claims are submitted with an appropriate diagnosis code from the applicable diagnosis-code list.

    • Blood glucose test strip quantity limit based on diagnosis

      • For gestational diabetes, diabetes in pregnancy, or diabetes with insulin use: up to 200/204 test strips per 30 days.200/204 per 30 days
      • For diabetes without insulin use: up to 100/102 test strips every 90 days.100/102 per 90 days

    Covered Products, Codes, and Quantity Limits

    Covered continuous glucose monitoring products and NDCsNDCCovered
    08627005303Dexcom G6 Sensor
    08627001601Dexcom G6 Transmitter
    08627007901Dexcom G7 15 Day Sensor
    08627007801Dexcom G7 Receiver
    08627007701Dexcom G7 Sensor
    57599000101FreeStyle Libre 14 Day
    57599083500FreeStyle Libre 2 Plus Sensor
    57599080300FreeStyle Libre 2 Reader
    57599080000FreeStyle Libre 2 Sensor
    57599084400FreeStyle Libre 3 Plus Sensor
    1–10 of 12
    1/2
    Covered CGM quantity-limit identifiersmixedCovered
    DEXCOM G6 RECEIVER1 per year
    DEXCOM G6 SENSOR3 per 30 days
    DEXCOM G6 TRANSMITTER1 per 90 days
    DEXCOM G7 15 DAY SENSOR2 per 30 days
    DEXCOM G7 RECEIVER1 per year
    DEXCOM G7 SENSOR3 per 30 days
    FREESTYLE LIBRE 14 DAY SENSOR2 per 28 days
    FREESTYLE LIBRE 2 PLUS SENSOR2 per 30 days
    FREESTYLE LIBRE 2 SENSOR2 per 28 days
    FREESTYLE LIBRE 3 PLUS SENSOR2 per 30 days
    1–10 of 11
    1/2
    Covered preferred blood glucose metersNDCCovered
    00193755301Contour Next EZ Meter System
    00193792201Contour Next Gen Meter
    00193782501Contour Next One Meter
    00193703601Contour Plus Blue Meter
    57599881401Precision Xtra Monitor
    56151149102ReliOn True Metrix Air Glucose Meter
    56151149002True Metrix Air Glucose Meter
    56151147002True Metrix Blood Glucose Meter
    Covered preferred blood glucose test stripsNDCCovered
    00193731025Contour Next Test Strip
    00193731150Contour Next Test Strip
    00193731221Contour Next Test Strip
    00193708050Contour Test Strip
    00193709021Contour Test Strip
    00193758450Contour Plus Test Strip
    56151146001True Metrix Glucose Test Strip
    56151146003True Metrix Glucose Test Strip
    56151146004True Metrix Glucose Test Strip
    56151146101ReliOn True Metrix Test Strip
    1–10 of 12
    1/2
    Covered blood glucose control solutionsNDCCovered
    56151145001True Metrix Level 1 Control Solution
    56151145002True Metrix Level 2 Control Solution
    56151145003True Metrix Level 3 Control Solution
    Covered external insulin pumps and related suppliesNDCCovered
    73108000008CeQur Simplicity 2U 4-day patch
    73108000100CeQur Simplicity inserter
    50050010115iLet infusion contact detach 23 inch, 6 mm
    50050010120iLet infusion contact detach 23 inch, 6 mm
    50050010010iLet infusion kit-inset 23 inch, 6 mm
    50050010015iLet infusion kit-inset 23 inch, 6 mm
    50050010210iLet infusion kit-inset 32 inch, 6 mm
    50050010215iLet infusion kit-inset 32 inch, 6 mm
    50050000401iLet starter kit contact 23 inch, 6 mm
    50050000201iLet starter kit-inset 23 inch, 6 mm
    1–10 of 16
    1/2
    Covered ketone strips, lancets, and lancing devicesNDCCovered
    57599074501Precision Xtra blood ketone strip
    56151060150TruePlus ketone test strip
    00193660601Microlet 2 lancing device
    00193654621Microlet lancets
    00193658621Microlet lancets
    00193670201Microlet Next lancing device
    56151014201TrueDraw lancing device
    56151014701TruePlus 33G lancets
    56151034101TruePlus safety 28G lancet
    56151034125TruePlus safety 28G lancet
    1–10 of 12
    1/2
    Covered preferred insulin pen needlesNDCCovered
    08290320550BD Nano 2 Gen pen needle 32G 4 mm
    08290320749BD Ultra-Fine Micro pen needle 6 mm x 32G
    08290320119BD Ultra-Fine Mini pen needle 5 mm x 31G
    08290320122BD Ultra-Fine Nano pen needle 4 mm x 32G
    08290328203BD Ultra-Fine Original pen needle 12.7 mm x 29G
    08290320109BD Ultra-Fine Short pen needle 8 mm x 31G
    83017055003Nano 2 Gen pen needle 32G 4 mm
    83017012203Nano pen needle 32G 4 mm
    08470342901Pentips pen needle 29G, 1/2 inch
    08470349001Pentips pen needle 31G, 1/4 inch
    1–10 of 16
    1/2
    Covered preferred insulin syringesNDCCovered
    10118089032AQ insulin syringe 0.5 mL, 30G, 8 mm
    10118089040AQ insulin syringe 1 mL, 31G, 8 mm
    08290328440BD insulin syringe 0.3 mL, 8 mm x 31G
    08290326730BD insulin syringe U-500, 0.5 mL, 6 mm x 31G
    08396801500CA insulin syringe 0.3 mL, 30G x 5/16 inch
    08489600910Droplet insulin syringe 0.3 mL, 30G x 12.5 mm
    59135000255Droplet insulin syringe 0.3 mL, 31G x 6 mm
    59135000265Droplet insulin syringe 0.3 mL, 31G x 8 mm
    08496303501Easy Touch 0.3 mL syringe, 30G x 1/2 inch
    08496305501Easy Touch 0.5 mL syringe, 30G x 1/2 inch
    1–10 of 22
    1/3
    Covered preferred diabetic supply POS edit identifiersNDCCovered
    08496301611Preferred-product POS edit source identifier shown for multiple Easy Touch, EQL, and related insulin syringe products.
    20221026018Preferred-product POS edit source identifier shown for multiple Exel and related insulin syringe products.
    11917001489Preferred-product POS edit source identifier shown for multiple insulin syringe products.
    90166085055Preferred-product POS edit source identifier shown for multiple 0.5 mL insulin syringe products.
    90166015655Preferred-product POS edit source identifier shown for multiple 0.5 mL and 1 mL insulin syringe products.
    90166085015Preferred-product POS edit source identifier shown for multiple 1 mL insulin syringe products.
    16784069591Preferred-product POS edit source identifier shown for multiple 1 mL, Kinray, and Kroger insulin syringe products.
    41260038512Preferred-product POS edit source identifier shown for Kroger, Leader, and MS insulin syringe products.
    38396043012Preferred-product POS edit source identifier shown for MS, Preferred Plus, Prodigy, and Publix insulin syringe products.
    41415001878Preferred-product POS edit source identifier shown for Publix, Rite Aid, and ReliOn insulin syringe products.
    1–10 of 13
    1/2
    Preferred CGM authorization bypass
    Insulin claim lookbackAt least 1 pharmacy claim within the previous 180 days
    CGM quantity limit
    Dexcom G6 receiver1 per year
    CGM quantity limit
    Dexcom G6 sensor3 per 30 days

    Authorization, Documentation, and Billing Actions

    Prior Authorization

    Submit the CGM Prior Authorization Form

    Use the Louisiana Uniform Prescription Drug Prior Authorization Form to request clinical authorization for continuous glucose-monitoring (CGM) devices.

    Note

    Preferred CGM Authorization Bypass

    A pharmacy claim for a preferred CGM bypasses the clinical authorization requirement when there is evidence of at least one pharmacy claim for insulin within the previous 180 days.

    Documentation Required

    Document CGM Initiation Criteria

    For initiation, document that the recipient meets at least one qualifying clinical pathway and include the required evidence on the request.

    Program and Product Definitions

    Participating Medicaid programs and MCOs
    Fee-for-ServiceLouisiana Medicaid Fee for Service Pharmacy Program
    Participating managed care entitiesAetna; AmeriHealth Caritas; Healthy Blue; Humana Healthy Horizons; Louisiana Healthcare Connections; and UnitedHealthcare
    Definition
    CGMContinuous glucose-monitoring devices subject to the listed clinical authorization, preferred-product, and quantity-limit rules.
    Definition
    Non-preferred continuous glucose monitorA continuous glucose monitor that is not identified as preferred and therefore requires an applicable exception or supporting documentation.
    Policy Summary
    PayerLouisiana Department of Health
    PolicyLouisiana Medicaid Diabetic Supplies List
    Policy CodePolicy N/A
    Change TypeNo material change
    Effective DateOct 1, 2025
    Next Review DateN/A
    Key ActionUse the Louisiana Uniform Prescription Drug Prior Authorization Form to request clinical authorization for continuous glucose-monitoring devices.
    SourceLink
    On This Page
    Coverage CriteriaCovered Products, Codes, and Quantity LimitsAuthorization, Documentation, and Billing ActionsProgram and Product Definitions
  1. Lancet claims are submitted with an appropriate diagnosis code from the applicable diagnosis-code list.

  2. Lancet quantity limit based on diagnosis

    • When used for gestational diabetes, diabetes in pregnancy, or diabetes with insulin use: up to 200/204 lancets per 30 days.200/204 per 30 days
    • When used for diabetes without insulin use: up to 100/102 lancets every 90 days.100/102 per 90 days
    3. CGM quantity limit
    Dexcom G6 transmitter1 per 90 days
    CGM quantity limit
    Dexcom G7 15 Day sensor2 per 30 days
    CGM quantity limit
    Dexcom G7 sensor3 per 30 days
    Blood glucose meter quantity limit
    Blood glucose meter1 meter per year
    Test-strip quantity limit
    Test strips for gestational diabetes, diabetes in pregnancy, or diabetes with insulin use200/204 test strips per 30 days
    Test-strip quantity limit
    Test strips for diabetes without insulin use100/102 test strips every 90 days
    Lancet quantity limit
    Lancets for gestational diabetes, diabetes in pregnancy, or diabetes with insulin use200/204 per 30 days
    Lancet quantity limit
    Lancets for diabetes without insulin use100/102 every 90 days
    • Diagnosis of diabetes of any type plus at least one pharmacy claim for insulin within the previous 180 days.
    • Level 2 (moderate) or level 3 (severe) hypoglycemia.
    • Glycogen storage disease type 1a.
    Documentation Required

    Document the Non-Preferred CGM Exception

    For a non-preferred CGM, document at least one approved exception on the request.

    • The recipient is continuing use of a non-preferred CGM.
    • The recipient had a trial of one preferred CGM with inadequate response or intolerance.
    • The recipient has limitations of use to the preferred CGM(s).
    • The recipient uses an insulin pump compatible only with a non-preferred CGM.
    Denial Risk

    Exclude Non-Qualifying Trial Evidence

    Do not count device samples, coupons, or discount cards as a qualifying preferred-CGM trial when documenting inadequate response or intolerance.

    • Samples, coupons, and discount cards are excluded from consideration as a trial.
    Documentation Required

    Document Continuation Follow-Up

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

    • Document the follow-up visit and assessment of ongoing benefit.
    Billing Rule

    Apply the CGM Approval Duration

    CGM approval for both initiation and continuation of therapy is limited to 6 months.

    • Initiation approval: 6 months.
    • Continuation approval: 6 months.
    Billing Rule

    Submit Diagnosis-Coded Test-Strip Claims

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

    • Gestational diabetes, diabetes in pregnancy, or diabetes with insulin use: 200/204 test strips per 30 days.
    • Diabetes without insulin use: 100/102 test strips every 90 days.
    Billing Rule

    Submit Diagnosis-Coded Lancet Claims

    Submit pharmacy claims for preferred lancets with an appropriate diagnosis code. The diagnosis code determines the applicable quantity limit.

    • Gestational diabetes, diabetes in pregnancy, or diabetes with insulin use: 200/204 lancets per 30 days.
    • Diabetes without insulin use: 100/102 lancets every 90 days.
    Billing Rule

    Apply the Meter Quantity Edit

    Apply the preferred blood glucose meter quantity edit: Medicaid covers no more than one meter per year under the preferred meter policy.

    • Quantity limit: 1 preferred blood glucose meter per year.
    Billing Rule

    Use the Preferred Package Size

    For preferred test strips and lancets, use the preferred package size and dispense up to the applicable diagnosis-based quantity limit based on the directions for use.

    • Test strips: use the preferred package size and dispense up to the applicable 30-day or 90-day limit.
    • Lancets: use the preferred package size and dispense up to the applicable 30-day or 90-day limit.
    Billing Rule

    Apply Preferred Diabetic Supply POS Edits

    Apply the preferred product-to-product POS mappings for the listed diabetic supplies when submitting claims. Use the preferred product/NDC mapping applicable to the billed item, including the listed preferred pen needles and insulin syringes.

    • Use the preferred product-to-product mappings listed for preferred pen needles and diabetic supply products.
    • Use the listed preferred mappings for insulin syringes across the documented sizes, gauges, volumes, and manufacturers.
    • Claims that do not use the applicable preferred mapping may fail the point-of-sale edit.
    Definition
    Preferred package sizeThe package size identified as preferred; use it when dispensing up to the applicable quantity limit based on the directions.
    Definition
    Preferred POS editA product identifier followed by an equals sign and one or more alternative product identifiers.