CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Diabetic Supplies for Pharmacy

Defines coverage, formulary preferences, prior authorization and quantity limits for diabetic testing supplies, meters, CGMs, and select insulin pumps for Medicaid, Commercial, and Medicare members covered by 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 change

Effective DateJan 1, 2019

Next Review DateN/A

Key ActionObtain prior authorization for non-formulary or non-preferred diabetic supplies, CGMs, and certain insulin pumps with documentation of trial and failure of formulary alternatives or justification for quantity exceptions.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

200/30dInsulin-dependent (Medicaid)

200/30dGestational (Medicaid)

204/30dCommercial test strip limit

12 monthsAuthorization duration

Coverage Criteria and Limitations

Coverage with criteria / Prior authorization exceptions

Covered when ALL of the following are met (authorization/organization determination exceptions):

General coverage conditions: Supply is on formulary/preferred list OR a prior authorization/organization determination approves non-formulary/non-preferred supply

Approval requires rationale why formulary/preferred alternatives are not appropriate and documentation of trial and failure of comparable formulary/preferred alternatives or justification for exceeding quantity limits

Quantity limits: Requested quantity does not exceed member-type specific limits OR a prior authorization/organization determination approves a quantity limit exceptionSee coding thresholds for limits by member type (e.g., Medicaid insulin-dependent 200/30 days; Commercial 204/30 days; Part B examples: insulin-dependent 4/day; gestational 4/day)

Quantities greater than allowed require prospective review via the authorization or organization determination process

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyDiabetic Supplies for Pharmacy

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 1, 2019

Next Review DateN/A

SourceLink

On This Page

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Provider Requirements and Prior Authorization

Prior Authorization

Prior Authorization Required

Prior authorization (or organization determination for Medicare Part B) is required for non-formulary / non-preferred diabetic supplies, continuous glucose monitors (CGMs), and certain insulin pumps. Requests will be reviewed prospectively and must justify why formulary/preferred alternatives are not appropriate for the member.

Applies to Medicaid, Commercial, and Part B/Part D lists where non-formulary or non-preferred devices are requested
Includes CGMs (e.g., FreeStyle Libre, Dexcom) and select pumps (e.g., Omnipod, V‑Go; other pumps such as Medtronic MiniMed or Tandem may require DME review)

Step Therapy

Step Therapy / Trial of Formulary Alternatives

Non-formulary/non-preferred diabetic supplies and devices will generally require trial and failure of comparable formulary/preferred alternatives prior to approval. The authorization/organization determination will consider evidence that the member has tried and failed the formulary/preferred options or that there is an appropriate clinical rationale why those alternatives are not appropriate.

Step therapy applies across benefit types (Medicaid, Commercial, Part B/Part D)
Quantity limits for formulary preferred test strips must be met or a quantity-exception demonstrated

Documentation Required

Authorization Documentation Requirements

When requesting prior authorization or an organization determination for a non-formulary or non-preferred diabetic supply, CGM, or insulin pump, submit documentation that supports medical necessity and exception to formulary or quantity limits.

Statement of clinical rationale explaining why preferred/formulary alternatives are not appropriate for the member
Documentation of trial and failure of comparable formulary/preferred alternatives, when applicable
If requesting a quantity limit exception, clinical evidence supporting need for quantities above the listed limits
For Part B organization determinations, include details required by Medicare process

Denial Risk

Benefit Exclusion — Stand‑alone Receiver Requirement

Continuous blood glucose monitors that do not operate with a stand‑alone receiver (i.e., require only a smartphone/app without a compatible receiver) will be denied as a benefit exclusion.

Applies to Part B/Part D coverage rules where specified in the formulary lists
Denials for this reason are benefit exclusions, not medical necessity denials

Background

Self-monitoring of blood glucose includes meters, test strips, lancets, and calibration solutions; coverage may also include continuous glucose monitors (CGMs) when clinically indicated. CGMs listed in the policy as covered with prior authorization and quantity limits include FreeStyle Libre and Dexcom. Coverage decisions for non-formulary or non-preferred supplies require prior authorization or an organization determination and must document why formulary/preferred alternatives are not appropriate and evidence of trial and failure of comparable alternatives or justification for exceeding quantity limits. Note that coverage and quantity limits vary by benefit type (Medicaid, Commercial, Part B/Part D) and authorization/organization determination processes apply for non-preferred items and quantity exceptions.

Formulary and Preference Definitions

Formulary / Preferred vs Non‑formulary / Non‑preferred — definitions

Definition — Formulary / Preferred suppliesDiabetic supplies listed as preferred/formulary include specified meters, test strips, lancets, calibration solutions, CGMs and certain pumps (examples: Accu‑Chek Guide meter; Accu‑Chek Guide, Aviva Plus, Smartview strips; Dexcom and FreeStyle Libre CGMs).

Non‑formulary / Non‑preferred suppliesSupplies not on the formulary/preferred list require prior authorization (or organization determination for Part B/Part D) with documentation of why preferred alternatives are not appropriate and evidence of trial and failure of comparable alternatives or justification for exceeding quantity limits.

Examples of formulary/preferred itemsMeters: Accu‑Chek Guide (Preferred), Accu‑Chek Aviva Plus; Test strips: Accu‑Chek Guide, Accu‑Chek Aviva Plus, Accu‑Chek Smartview; Lancets: any; Calibration solutions: Accu‑Chek Solution and listed controls.

CGMs and pumpsDexcom and FreeStyle Libre are listed as formulary/preferred but require prior authorization and quantity limits; some insulin pumps (e.g., Omnipod, V‑Go) are covered with prior authorization while other pumps (e.g., Medtronic MiniMed, Tandem) may be DME‑only and not pharmacy‑covered.

OpenPayer

Diabetic Supplies for Pharmacy

Coverage Criteria and Limitations

Quantity Limits and Coding Notes

Provider Requirements and Prior Authorization

Background

Formulary and Preference Definitions