Pharmacy Prior Authorization Criteria

Blood Glucose Monitor & Test Strips - ST, QL, NF

Indications for Prior Authorization

Blood glucose monitoring systems

• For diagnosis of Quantitative measurements of glucose
  Intended to be used for quantitative measurements of glucose in fresh capillary and/or venous whole blood. Various devices are designed for testing by persons with diabetes or by health care professionals in the home or health care facilities.

Criteria

Non-preferred test strip products

Step Therapy

Length of Approval: 12 Month(s)

• Requested product is being used for a Food and Drug Administration (FDA)-approved indication
AND
• One of the following:
• Trial to a minimum 90 day supply of both Contour Next and OneTouch test strips within the last 180 days
OR
• The non-preferred test strip is required because it is the only product that will interface with the member’s insulin pump

Non-Formulary or Excluded test strip products

Non Formulary

Length of Approval: 12 Month(s)

• Submission of medical records (e.g., chart notes) confirming that the non-formulary/excluded test strip is required because it is the only product that will interface with the member’s insulin pump

Preferred or non-preferred test strip products

Quantity Limit

Length of Approval: 12 Month(s)

• Physician confirmation that the patient requires a greater quantity because of more frequent blood glucose testing (e.g., patients on intravenous insulin infusions) [A]

Non-preferred meter products

Step Therapy

Length of Approval: 12 Month(s)

• Requested product is being used for a Food and Drug Administration (FDA)-approved indication
AND
• One of the following:
• Minimum 1-day trial of both a Contour Next Blood Glucose Monitoring System (e.g. Contour Next EZ Blood Glucose Monitoring System) and a OneTouch Blood Glucose Monitoring System within the last 365 days
OR
• The non-preferred meter is required because it is the only product that will interface with the member’s insulin pump

Non-Formulary or Excluded meter products

Non Formulary

Length of Approval: 12 Month(s)

• Submission of medical records (e.g., chart notes) confirming that the non-formulary/excluded meter is required because it is the only product that will interface with the member’s insulin pump

P & T Revisions

2024-09-23, 2024-06-20, 2023-06-22, 2023-01-19, 2022-08-31, 2022-06-16, 2022-04-12, 2021-09-17, 2021-06-29, 2021-05-25, 2021-04-02, 2020-08-07

References

1. American Diabetes Association (ADA). Diabetes Technology: Standards of Medical Care in Diabetes - 2023. Diabetes Care. 2023;46(suppl 1):S111-S127.

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End Notes

1. The evidence regarding the utility and optimal frequency of blood glucose monitoring (BGM) is not well defined for patients who do not use intensive insulin regimens, such as those with type 2 diabetes using oral agents and/or basal insulin [1]. However for most patients using intensive insulin regimens (multiple-dose insulin or insulin pump therapy) BGM should be performed prior to meals and snacks, at bedtime, occasionally postprandially, prior to exercise, when they suspect low blood glucose, after treating low blood glucose until they are normoglycemic, and prior to and while performing critical tasks such as driving [1].

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Revision History

• 2024-09-23: Added back a couple GPI 14s for PA operation purposes.
• 2024-06-20: 2024 annual review: updated GPI for Quantity Limit criteria section, now managing at GPI 8 level for ease of maintenance.
• 2023-06-22: Annual review: updated trial duration and lookback period for "non-preferred meter products" to 1-day trial within the last 365 days.
• 2023-01-19: Addition of non-preferred meter product, Tempo Kit
• 2022-08-31: Addition of PTS Panel Test Strip
• 2022-06-16: Annual review: Updated GL Name to include ST, QL, NF guideline types. Added "Requested product is being used for a Food and Drug Administration (FDA)-approved indication" for the two Step Therapy sections.
• 2022-04-12: Update to add GPIs 97202010006200 (Freestyle Lite) and 97202010006410 (OneTouch Ultra 2 Kit)
• 2021-09-17: Modified "Non-preferred test strip products" and "Non-preferred meter products" ST criteria sections to add OneTouch as an additional required option. Background updates.
• 2021-06-29: For NF criteria sections: added requirement for submission of medical records, and removed trial/failure criteria.
• 2021-05-25: Addition of EHB formulary to guideline, no changes to criteria
• 2021-04-02: Added note that this guideline does not apply to CGMs.
• 2020-08-07: Cotour Next preferred, change; updated verbiage for day supply requirement and submission verbiage change

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