Blood Glucose Test Strips
SELF ADMINISTRATION
The following are the preferred Blood Glucose Test Strips:
- Freestyle Insulinx
- Freestyle Lite
- Freestyle
- Precision Xtra
- Onetouch Ultra
- Onetouch Verio
All other Blood Glucose Test Strips are non-preferred and require prior authorization
Patients must meet the following criteria for all non-preferred Blood Glucose Test Strips:
- Medical record documentation is provided and supports a medically appropriate reason why the preferred Brand Test Strips (i.e., Freestyle Insulinx, Freestyle Lite, Freestyle, Precision Xtra, Onetouch Ultra, Onetouch Verio) cannot be considered
Approval:
- 1 year
Last review date: August 21, 2020