CurrentMass General Brigham Health PlanPolicy N/A

Non-Formulary Diabetic Supplies & Test Strip Quantity Limit

Policy defines prior authorization and quantity limit criteria for coverage of non-formulary blood glucose meters and diabetic test strips under the pharmacy benefit for Commercial/Exchange members; includes exceptions for insulin pump users and ketone strip users and duration limits for authorizations.

Policy Summary

PayerMass General Brigham Health Plan

PolicyNon-Formulary Diabetic Supplies & Test Strip Quantity Limit

Policy CodePolicy N/A

Change TypeRevised (ketone strips added; Comm/Exch separated from MassHealth)

Effective DateJul 1, 2021

Next Review Date

Key ActionPrior authorization is required for non-formulary meters and test strips; document insulin pump or ketone strip use and request 24-month authorization when applicable.

SourceLink

POLICY UPDATE CHANGES

Separated Commercial/Exchange vs. MassHealth UPPL and set effective date 07/01/2021.

Added criteria for ketone strips.

3Post-limit eligible clinical scenarios

24 monthsAuthorization duration

≤8/dayStandard daily test strip limit

Coverage Summary

Policy governs pharmacy benefit coverage of non-formulary blood glucose meters and diabetic test strips for Commercial/Exchange members and is covered with criteria. Coverage requires prior authorization and is subject to quantity limits under the pharmacy benefit. Key thresholds: authorization duration = 24 months and the standard daily test strip limit is ≤ 8 test strips per day (exceptions allowed for documented medical need).

Quick Facts

Coverage stancecovered_with_criteria

Standard daily test strip limit≤8 test strips per day

Authorization duration24 months

Medical-Necessity Criteria

Non-Formulary Meter

Covered when ONE of the following is met:

ONE of

The member is on an insulin pump that requires the corresponding meter
The member is using non-formulary meter with ketone strips

Non-Formulary Diabetic Test Strips

Covered when BOTH of the following are met:

ALL of the following

The member is on an insulin pump that requires non-formulary test strips for the corresponding meter OR requires non-formulary test strips because member has ketone test strips which are being used for the corresponding meter
ONE of
- The requested quantity is for no more than 8 test strips per day≤ 8 test strips per day
- The member has a medical need for testing more frequently than 8 times per day

ref

Diabetic Test Strips Post Limit (Post-Limit Coverage)

Covered when ONE of the following is met:

ONE of

The member has been diagnosed with gestational diabetes or a short-term condition
The patient is on an insulin pump
The patient has documented poor or fluctuating blood sugar control

Authorization Duration

ALL of the following

Initial authorizations and reauthorizations will be granted for 24 months24 months

Provider Actions & Requirements

Prior Authorization

Prior Authorization required for non-formulary diabetic supplies

Prior authorization is required for non-formulary meters and test strips under the pharmacy benefit for Commercial/Exchange members. Approvals follow the clinical criteria in this policy and must be obtained before coverage is provided.

Documentation Required

Document insulin pump or ketone strip use

Provider must document that the member is on an insulin pump that requires the corresponding meter/test strips or is using ketone strips tied to the corresponding meter in order to meet the coverage criteria.

Documentation Required

Document medical need for >8 strips/day

When requesting more than 8 test strips per day, the provider must document a medical need for testing more frequently than 8 times per day to meet the exception criterion.

Billing Rule

Authorization duration

Initial authorizations and reauthorizations are granted for 24 months. Ensure the authorization period is requested and entered accordingly when submitting authorization requests.

Background

This policy governs pharmacy benefit coverage of non-formulary blood glucose meters and test strips for Commercial/Exchange members. It includes special consideration for members using insulin pumps (coverage may be granted when the member is on an insulin pump that requires the corresponding meter or test strips) and for members using ketone strips tied to a corresponding non-formulary meter. Prior authorization is required for non-formulary meters and test strips, and quantity limits apply (standard test strip quantity limit is ≤ 8 per day). Initial authorizations and reauthorizations are granted for 24 months. Providers must document insulin pump use, ketone strip use, or a medical need if requesting more than 8 test strips per day to meet criteria.