CurrentNeighborhood Health Plan of Rhode IslandPolicy PHA

Diabetic Supplies for Pharmacy

Rules for coverage, formulary lists, quantity limits, and prior authorization/organization determination requirements for diabetic supplies billed through the pharmacy benefit or Part B/Part D for Neighborhood Health Plan of Rhode Island members (Medicaid, Commercial, and INTEGRITY Medicare-Medicaid Plan).

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyDiabetic Supplies for Pharmacy

Policy CodePolicy PHA

Change TypeNo material changes

Effective DateJan 1, 2019

Next Review Date

Key ActionObtain prior authorization or organization determination for non-formulary/non-preferred diabetic supplies or for quantities above program limits, documenting trial/failure of formulary alternatives or rationale why alternatives are inappropriate.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

12 monthscoverage duration

200/30 daysMedicaid limit

204/25 daysCommercial limit

4/dayINTEGRITY limit

Accu‑Chek listedPreferred meters/strips

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Coverage Criteria for Diabetic Supplies

Coverage criteria

Covered when meeting program-specific formulary and quantity rules and authorization/organization determination requirements.

General coverage: Diabetic supplies are covered under Part B for INTEGRITY members at the Pharmacy and under the Pharmacy Benefit for Medicaid and Commercial members when used within the guidelines; use outside of these guidelines may result in non-payment unless approved via the exception/organization determination/prior authorization process.

Refer to program-specific formulary and authorization requirements.

Formulary items by program

Medicaid formulary: Meters: Accu-Chek Guide (Preferred), Accu-Chek Aviva Plus, Accu-Chek Nano; Test strips: Accu-Chek Guide, Accu-Chek Aviva Plus, Accu-Chek Smartview, Accu-Chek Compact Plus; Lancets: Any; Calibration solutions: Accu-Chek Solution variants; CGMs: FreeStyle Libre (PA and qty limits) and Dexcom; Insulin pumps: Omnipod (PA and qty limits).
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Commercial formulary: Meters: Accu-Chek Guide (Preferred), Accu-Chek Aviva Plus, Accu-Chek Nano; Test strips: Accu-Chek Guide, Accu-Chek Aviva Plus, Accu-Chek Smartview, Accu-Chek Compact Plus; Lancets: Any; Calibration solutions: Accu-Chek Solution variants; CGMs: Dexcom; Insulin pumps: Omnipod, V-Go Kit.
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INTEGRITY (MMP) formulary: Preferred Part B supplies: Meters: Accu-Chek Guide (Preferred), Accu-Chek Aviva Plus, Accu-Chek Nano; Test strips: Accu-Chek Guide, Accu-Chek Aviva Plus, Accu-Chek Smartview, Accu-Chek Compact Plus; Lancets: Any; Calibration solutions: Accu-Chek Solution variants; CGMs: Dexcom, FreeStyle Libre; Part D insulin pumps: Omnipod, V-Go Kit (PA and qty limits).
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Quantity limits

Medicaid quantity rules: Insulin dependent: 200 test strips per 30 days; Gestational diabetes: 200 test strips per 30 days; Non-insulin dependent: 1 test strip per day (50 per 50 days). Quantities greater than allowed require prior authorization and appropriate rationale.200/30 days or as specified
[[chunk 4]]
Commercial quantity rules: 204 test strips per 25 days. Quantities greater than allowed require prior authorization and appropriate rationale.204/25 days
[[chunk 5]]
INTEGRITY quantity rules: Insulin dependent: 4 test strips per day (e.g., 100 per 25 days); Gestational diabetes: 4 per day; Non-insulin dependent: 100 test strips per 68 days. Quantities greater than allowed require organization determination with appropriate rationale.4/day (~100/25 days)

Authorization exceptions / step therapy: Non-formulary or non-preferred supplies and requests for quantities above limits will be reviewed prospectively; approval requires documented trial and failure of comparable formulary/preferred alternatives or a documented rationale why alternatives are inappropriate.

Prior authorization for Medicaid/Commercial; organization determination for INTEGRITY (Part B).

Any continuous blood glucose monitor that does not work with a stand-alone receiver is excluded from coverage and will be denied as a benefit exclusion. The policy lists FreeStyle Libre 3 as an example of a device denied for this reason.

Diabetic products that are not available through the pharmacy because they are considered durable medical equipment (DME-only) are not covered under the pharmacy benefit. Examples include insulin pumps not listed on the formulary (e.g., V-Go Kit, Medtronic MiniMed, Tandem AutoSoft) and other insulin pumps noted as DME in the formulary sections.

Preferred NDCs and Coding

Preferred NDCsNDCCovered

97202027006300	Category = LANCET DEVICES**; NDC = All NDCs
97202030006400	Category = LANCET KIT**; NDC = All NDCs
97202025006300	Category = LANCETS**; NDC = All NDCs
97202007100900	BLOOD GLUCOSE CALIBRATION - LIQUID; NDCs: 65702010710 (ACCU-CHEK SOL), 65702048810 (ACCU-CHEK LIQ SMART), 65702046810 (ACCU-CHEK SOL COMPACT), 65702071310 (ACCU-CHEK LIQ GUIDE), 65702068810 (ACCU-CHEK LIQ GUIDE)
97202010006410	BLOOD GLUCOSE MONITORING KITS; NDCs: 65702072310 (ACCU-CHEK KIT AVIVA PL), 65702061710, 65702072910 (ACCU-CHEK KIT GUIDE), 65702048310 (ACCU-CHEK KIT NANO)
94100030006100	GLUCOSE BLOOD TEST STRIP; NDCs: 65702071110 (ACCU-CHEK TES GUIDE), 65702071210, 65702040710, 65702040810, 50924098850, 50924088401, 65702049210, 65702049310 (ACCU-CHEK TES SMART)

Provider Actions, Prior Authorization, and Documentation

Denial Risk

Exception / non-payment risk

Use outside of these guidelines may result in non-payment unless approved under the exception process.

Prior Authorization

Prior authorization / organization determination required

Non-formulary or non-preferred diabetic supplies and quantities greater than allowed require prior authorization or organization determination review. The review will determine that the member has tried and failed comparable formulary/preferred alternatives OR that there is an appropriate rationale why the formulary/preferred alternatives or quantity limits are not appropriate for the member.

Non-formulary supplies (Medicaid/Commercial/Part D) require prospective prior authorization.
Non-preferred Part B testing supplies require organization determination review.

Background

This document addresses coverage rules for diabetic supplies dispensed through the pharmacy benefit (and Part B for INTEGRITY members). It specifies the preferred meters, test strips, lancets, calibration solutions, continuous glucose monitors, and insulin pumps for Medicaid, Commercial, and INTEGRITY programs, details program-specific quantity limits for test strips, and outlines prior authorization or organization determination requirements for non-formulary/non-preferred supplies or requests exceeding quantity limits. Use outside these guidelines may result in non-payment unless approved through the exception, prior authorization, or organization determination processes.