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

    Louisiana Medicaid Diabetic Supplies List

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    This policy identifies diabetic supplies reimbursable through the Louisiana Medicaid Fee for Service Pharmacy Program and participating Managed Care Organizations. It governs preferred products, pharmacy claim submission requirements, quantity limits, and clinical prior authorization criteria for continuous glucose monitors and other diabetic supplies.

    Policy Summary
    PayerLouisiana Department of Health
    PolicyLouisiana Medicaid Diabetic Supplies List
    Policy CodePolicy N/A
    Change TypeNo material change
    Effective DateOct 1, 2026
    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 daysHigher-use strip/lancet limit

    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 daysLower-use strip/lancet limit
    5Participating MCOs

    Coverage Criteria

    CGM initiation criteria

    Covered for initiation when the recipient meets ONE of the following conditions:

    ONE of

    • Diagnosis of diabetes of any type with evidence of at least one pharmacy claim for insulin within the previous 180-day period
    • Evidence of level 2 (moderate) or level 3 (severe) hypoglycemia
    • Glycogen storage disease type 1a

    Non-preferred CGM criteria

    A non-preferred CGM also requires ONE of the following documented circumstances:

    ONE of

    • The recipient is continuing use of a non-preferred continuous glucose monitor
    • The recipient had a trial of one preferred continuous glucose monitor followed by inadequate response or intolerance; device samples, coupons, and discount cards do not count as a trial

      Document the qualifying trial and its outcome.

    • The recipient has limitations of use to the preferred continuous glucose monitor or monitors
    • The recipient is utilizing an insulin pump that is only compatible with a non-preferred continuous glucose monitor

    CGM continuation criteria

    Continuation requests require the following:

    ALL of the following

    • The prescriber states on the request that the recipient attended a follow-up visit with a healthcare provider to assess the ongoing benefits of CGM therapy

    Test strip and lancet claim criteria

    Covered claims must meet BOTH the diagnosis-code and diagnosis-specific quantity requirements:

    ALL of the following

    • The pharmacy claim includes an appropriate diagnosis code identified by the program

    • Applicable quantity limit

      • For gestational diabetes, diabetes in pregnancy, or diabetes with insulin use: test strips do not exceed 200/204 per 30 days, or lancets do not exceed 200/204 per 30 days
      • For diabetes without insulin use: test strips do not exceed 100/102 every 90 days, or lancets do not exceed 100/102 every 90 days

    Covered Products and Quantity Limits

    Continuous glucose monitors and sensorsNDCCovered
    08627009111Dexcom G6 Receiver
    08627005303Dexcom G6 Sensor
    08627001601Dexcom G6 Transmitter
    08627007901Dexcom G7 15 Day Sensor
    08627007801Dexcom G7 Receiver
    08627007701Dexcom G7 Sensor
    57599000200Freestyle Libre 14 Day
    57599000101Freestyle Libre 14 Day Reader
    57599083500Freestyle Libre 2 Plus Sensor
    57599080000Freestyle Libre 3 Plus
    1–10 of 13
    1/2
    CGM quantity limitsmixedCovered
    2 per 28 daysFreestyle Libre 2 Sensor quantity limit
    2 per 30 daysFreestyle Libre 3 Plus Sensor quantity limit
    1 per yearFreestyle Libre 3 Reader quantity limit
    2 per 28 daysFreestyle Libre 3 Sensor quantity limit
    5 per 30 daysGuardian 4 Glucose Sensor quantity limit
    1 per yearGuardian 4 Transmitter quantity limit
    1 per yearGuardian Link 3 Transmitter quantity limit
    5 per 30 daysGuardian Sensor 3 quantity limit
    Preferred blood glucose metersNDCCovered
    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
    56151212101TruEness Blood Glucose Monitor
    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
    56151146101Relion True Metrix Test Strip
    56151212205TruEness Glucose Test Strip
    Blood glucose control solutionsNDCCovered
    56151145001True Metrix Level 1 Control Solution
    56151145002True Metrix Level 2 Control Solution
    56151145003True Metrix Level 3 Control Solution
    Ketone strips and insulin delivery suppliesNDCCovered
    57599074501Precision Xtra blood ketone strip
    56151060150TruePlus ketone test strip
    73108000008CeQur Simplicity 2U 4Day Patch
    08508300021Omnipod 5 DexG7G6 Pods Gen 5
    08508300088Omnipod 5 Intro G6/Libre 2 Plus
    08508200005Omnipod Dash Pods Gen 4 5-pack
    Preferred lancets and lancing devicesNDCCovered
    00193654621Microlet lancets
    00193658621Microlet lancets
    00193602021Microlet Next 28G lancet
    00193670201Microlet Next lancing device
    56151014201TrueDraw lancing device
    56151014701TruePlus 33G lancets
    56151014260TruePlus Super Thin 28G lancet
    56151014401TruePlus Ultra Thin 30G lancet
    56151014402Ultra Thin lancets
    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
    08470342901Pentips pen needle 29G 1/2 inch
    83017820303Ultra-Fine pen needle 29G 12.7 mm
    08470359001Unifine Pentips 6 mm 31G
    08470794001Unifine SafeControl 32G 4 mm
    Insulin syringesNDCCovered
    08290328440BD insulin syringe 0.3 mL 8 mm x 31G
    08290326730BD insulin syringe U-500 1/2 mL 6 mm x 31G
    08290328431BD Ultra-Fine insulin syringe 0.3 mL 12.7 mm x 30G
    08489605110Droplet 0.5 mL 29G x 12.5 mm syringe
    83017673003Insulin syringe U-500 0.5 mL 31G 6 mm
    56151171101TruePlus 0.3 mL 29G x 1/2 inch syringe
    83017841103Ultra-Fine insulin syringe 1 mL 30G 12.7 mm
    Preferred CGM insulin-claim lookback
    Lookback periodPrevious 180 days
    Qualifying evidenceAt least one pharmacy claim for insulin
    Effect for preferred CGM claimsEvidence of the qualifying insulin claim bypasses the clinical authorization requirement
    CGM approval duration
    Initiation approval6 months

    Authorization and Claim Submission

    Prior Authorization

    Submit CGM prior authorization requests

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

    Documentation Required

    Document initiation criteria

    For initiation of CGM therapy, state on the request that the recipient meets at least one qualifying condition.

    • Diabetes of any type with evidence of 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.

    Program and Product Definitions

    Participating Medicaid programs
    Fee for Service programLouisiana Medicaid Fee for Service Pharmacy Program
    Managed Care OrganizationsAetna; AmeriHealth Caritas; Healthy Blue; Humana Healthy Horizons; and Louisiana Healthcare Connections
    Reimbursing entitiesThe listed programs and organizations reimburse pharmacy claims for the diabetic supplies in the list
    Preferred and non-preferred products
    Preference categoriesProducts are identified as preferred or non-preferred
    Preferred product codingPreferred products are listed with their associated National Drug Codes (NDCs)
    Policy Summary
    PayerLouisiana Department of Health
    PolicyLouisiana Medicaid Diabetic Supplies List
    Policy CodePolicy N/A
    Change TypeNo material change
    Effective DateOct 1, 2026
    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 and Quantity LimitsAuthorization and Claim SubmissionProgram and Product Definitions
    Continuation approval6 months
    Applies toCGM therapy initiation or continuation
    CGM quantity limits
    Receivers and readers1 per year
    Transmitters1 per 90 days or 1 per year, depending on product
    Sensors2 per 28 days, 2 per 30 days, 3 per 30 days, or 5 per 30 days, depending on product
    Freestyle Libre 2 Sensor2 per 28 days
    Freestyle Libre 3 Plus Sensor2 per 30 days
    Guardian 4 Glucose Sensor and Guardian Sensor 35 per 30 days
    Blood glucose meter limit
    Annual limit1 blood glucose meter per year
    Product categoryBlood glucose meters
    Claim controlThe meter limit is applied through preferred blood glucose meter point-of-sale edits
    Test strips for diabetes with insulin use
    Applicable useGestational diabetes, diabetes in pregnancy, or diabetes with insulin use
    Quantity limit200/204 blood glucose test strips per 30 days
    Package-size instructionUse the preferred package size and dispense up to the quantity limit based on directions
    Test strips for diabetes without insulin use
    Applicable useDiabetes without insulin use
    Quantity limit100/102 blood glucose test strips every 90 days
    Package-size instructionUse the preferred package size and dispense up to the quantity limit based on directions
    Lancets for diabetes with insulin use
    Applicable useGestational diabetes, diabetes in pregnancy, or diabetes with insulin use
    Quantity limit200/204 lancets per 30 days
    Package-size instructionUse the preferred package size and dispense up to the quantity limit based on directions
    Lancets for diabetes without insulin use
    Applicable useDiabetes without insulin use
    Quantity limit100/102 lancets every 90 days
    Package-size instructionUse the preferred package size and dispense up to the quantity limit based on directions
    Documentation Required

    Document non-preferred CGM exception

    For a non-preferred CGM, document at least one qualifying exception or clinical circumstance on the request.

    • The recipient is continuing use of a non-preferred continuous glucose monitor.
    • The recipient had a trial of one preferred continuous glucose monitor and an inadequate response or intolerance.
    • 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 nonpreferred continuous glucose monitor.
    Step Therapy

    Apply preferred-device trial rule

    When documenting a preferred CGM trial, do not count device samples, coupons, or discount cards as a qualifying trial.

    Documentation Required

    Document continuation follow-up

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

    Billing Rule

    Apply 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-day period.

    Billing Rule

    Submit diagnosis-linked test-strip claims

    Submit pharmacy claims for blood glucose test strips with an appropriate diagnosis code identified by the program. Quantity limits depend on the diagnosis code submitted on the pharmacy claim.

    • 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.
    • Use the preferred package size and dispense up to the quantity limit based on directions.
    Billing Rule

    Submit diagnosis-linked lancet claims

    Submit pharmacy claims for lancets with an appropriate diagnosis code identified by the program. Quantity limits depend on the diagnosis code submitted on the pharmacy claim.

    • 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.
    • Use the preferred package size and dispense up to the quantity limit based on directions.
    Prior Authorization

    Contact the applicable authorization entity

    Use the applicable prior authorization contact number for the recipient’s Managed Care Organization or Fee-for-Service program when seeking pharmacy prior authorization information.

    • Aetna Better Health of Louisiana: 1-855-242-0802.
    • AmeriHealth Caritas Louisiana: 1-800-684-5502.
    • Fee-for-Service Louisiana Legacy Medicaid: 1-866-730-4357.
    • Healthy Blue: 1-844-521-6942.
    • Humana: 1-800-555-2546.
    • Louisiana Healthcare Connections: 1-866-595-8133.
    Non-preferred product coding
    Non-preferred products are listed with their associated National Drug Codes (NDCs)
    Continuous glucose monitoring
    Meaning of CGMContinuous glucose-monitoring device or product
    Authorization formUse the Louisiana Uniform Prescription Drug Prior Authorization Form to request clinical authorization
    Coverage conditionCGMs are subject to the listed clinical authorization criteria
    Point-of-sale edits
    Product preference controlPoint-of-sale edits apply preferred and non-preferred product requirements
    Diagnosis-code requirementPharmacy claims for blood glucose test strips and lancets must include an appropriate diagnosis code identified by the program
    Quantity-limit controlLimits for test strips and lancets depend on the diagnosis code submitted on the pharmacy claim