CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Diabetic Supplies for Pharmacy

Coverage and prior authorization rules for diabetic supplies billed at retail pharmacies for Medicaid, Commercial, and INTEGRITY (Medicare-Medicaid) members of Neighborhood Health Plan of Rhode Island.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyDiabetic Supplies for Pharmacy

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date01/01/2019

Next Review DateN/A

Key ActionObtain prior authorization for non-formulary or non-preferred diabetic supplies, documenting trial and failure of formulary alternatives or medical rationale for exception.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

200/30dMedicaid insulin-dependent / gestational limit

204/30dCommercial test strip limit

4/dayPreferred (Part B) daily limit

12 monthsCoverage period

Coverage Criteria for Diabetic Supplies Dispensed at Pharmacy

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General coverage criteria

Covered when criteria below are met by benefit and member type

Benefit assignment: Supplies billed at Pharmacy are covered under Part B for INTEGRITY members and under the Pharmacy Benefit for Medicaid and Commercial members when used within guidelines

Use outside guidelines may result in non-payment unless approved via exception process

Formulary / preferred product: Item is a formulary or preferred diabetic supply listed for the member's benefit (examples: Accu‑Chek Guide meter and strips, Accu‑Chek Aviva Plus, Accu‑Chek Smartview, Dexcom, FreeStyle Libre, Omnipod, V‑Go where listed)

Non‑formulary or non‑preferred supplies require prior authorization or organization determination confirming trial and failure of formulary/preferred alternatives or documented medical rationale

Quantity limits: Requested quantities must be within the stated quantity limits for the member category; quantities greater than allowed require prior authorization or organization determination with documented rationaleSee 'Test strip quantity limits' (Medicaid: insulin‑dependent/gestational 200/30 days; non‑insulin dependent 1/day (≈50/50 days); Commercial: 204/30 days; Preferred/Part B: insulin‑dependent/gestational 4/day (100/25 days); non‑insulin dependent 100/68 days)

Organization determination/prior authorization will evaluate reason for exception

Diabetic products that are not stocked or dispensed through retail pharmacies are considered durable medical equipment (DME) and are not covered under the pharmacy benefit. Examples include insulin pumps and other devices not listed as formulary pharmacy items (e.g., Medtronic MiniMed, Tandem AutoSoft, V-Go Kit where applicable). Such DME-only items must be obtained and billed through the DME/medical benefit rather than the pharmacy benefit.

Therapies used at doses or for conditions that are not recognized as medically accepted indications in standard compendia or the peer-reviewed literature are considered investigational and are not covered. The recognized references include AHFS-DI, Micromedex DrugDex, Clinical Pharmacology, Wolters Kluwer Lexi-Drugs, or peer-reviewed published medical literature demonstrating sufficient evidence to support use.

Coding and Product Lists

Covered device/product lists (by name)mixed

Accu-Chek Guide	Meter / Test Strips (Preferred)
Accu-Chek Aviva Plus	Meter / Test Strips
Accu-Chek Smartview	Test Strips
AccuChek Compact Plus	Test Strips
Any	Lancets
Accu-Chek Solution	Calibration Solution
Accu-Chek Liquid Smart Control	Calibration Solution
AccuChek Liquid Guide Control	Calibration Solution
Accu-Chek Guide Control	Calibration Solution
Dexcom	Continuous Glucose Monitor (CGM)

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Test strip quantity limits — by member type and benefit

Medicaid — insulin-dependent / gestational200 test strips per 30 days

Medicaid — non-insulin dependent1 test strip per day (i.e., 50 test strips per 50 days)

Commercial — all members204 test strips per 30 days

Preferred (Part B) — insulin-dependent / gestational4 test strips per day (e.g., 100 test strips per 25 days)

Preferred (Part B) — non-insulin dependent100 test strips per 68 days

Provider Requirements and Prior Authorization

Prior Authorization

Prior Authorization Required

Prior authorization is required for non-formulary/non-preferred diabetic supplies. Non-formulary or non-preferred testing supplies and diabetic products will require prospective review via the prior authorization or organization determination process before coverage is approved.

Non-formulary supplies (Medicaid/Commercial) and non-preferred testing supplies (Part B) require prior authorization/organization determination.
Prior authorization requests must document medical necessity and any applicable quantity-limit exceptions.
Coverage duration for approved supplies: 12 months.

Step Therapy

Step Therapy / Failure of Alternatives

Requests are evaluated to ensure the member has tried and failed comparable formulary/preferred alternatives or that there is an appropriate clinical rationale why the formulary/preferred alternatives are not appropriate for the member.

Approval criteria include documentation that the member tried and failed comparable formulary/preferred alternatives OR documentation of an appropriate clinical rationale for why alternatives are not appropriate.
Examples: clinical intolerance, device incompatibility, or documented treatment failure with formulary/preferred products.

Documentation Required

Prior Authorization Rationale

When requesting prior authorization, include documentation that supports the rationale for approving a non-formulary/non-preferred supply (e.g., failure of formulary alternatives, clinical contraindication, or other medical justification).

If requesting quantities above the stated limits, supply documentation showing why the quantity limit is not appropriate for the member.
Non-formulary or non-preferred requests must specify the formulary alternatives attempted and the outcomes or provide a clear clinical rationale.

Denial Risk

Benefit Exclusion — CGM Receiver Requirement

Any continuous glucose monitor (CGM) that does not work with a stand-alone receiver will be denied as a benefit exclusion.

Denial applies to CGMs requiring connection to a smartphone only when a stand-alone receiver option is not available.

Background

Diabetic monitoring supplies include a range of products dispensed at pharmacies such as blood glucose meters, test strips, lancets, calibration/control solutions, continuous glucose monitors (CGMs), and certain insulin pump systems listed on the formulary. Coverage and quantity limits vary by benefit and member type: Medicaid and Commercial formularies identify preferred meters and strips (examples: Accu‑Chek Guide, Accu‑Chek Aviva Plus; Dexcom and FreeStyle Libre for CGMs where prior authorization and quantity limits apply), while items not available at retail pharmacy are DME-only. Prior authorization is required for non-formulary or non-preferred supplies and for quantities exceeding stated limits; coverage duration is 12 months.

Formulary and Preferred Supplies (Definitions)

Formulary / preferred diabetic supplies (examples by benefit)

Preferred meters (Medicaid/Commercial/Part B)Accu-Chek Guide (Preferred), Accu-Chek Aviva Plus

Preferred test stripsAccu-Chek Guide, Accu-Chek Aviva Plus, Accu-Chek Smartview, (AccuChek Compact Plus listed for Part B)

LancetsAny

Calibration solutionsAccu-Chek Solution; Accu-Chek Liquid Smart Control; AccuChek Liquid Guide Control; Accu-Chek Guide Control (AccuChek Solution Compact Plus / Compact Plus Clear noted for Part B)

Continuous glucose monitors (CGMs)Dexcom, FreeStyle Libre (both may require prior authorization and quantity limits)

Insulin pumps (formulary/Part D)Omnipod (Prior Authorization and Quantity Limits apply); V-Go Kit (Part D listing; PA/quantity limits apply)