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Diabetic Testing Supplies

Overview

Blood glucose testing supplies and insulin needles are now billed at the pharmacy point of sale (POS) system.

Effective January 1, 2020, Continuous Glucose Monitors (CGM) will be available at pharmacies and billed through the pharmacy POS system. There will be a grace period from January 1st, 2020 to February 29, 2020 to help transition members. At that time, all CGM supplies will need to be dispensed from a contracted pharmacy provider.

Preferred blood glucose testing supplies and CGM products can be found below.

Billing  

Claims for the preferred blood glucose testing supplies and CGM will not count against the members monthly script limit. These products will also be available with no copay.

Supplies for insulin pumps will continue to be billed through the DME process.

Claims for Medicaid/Medicare dual eligible members are not affected by this changes and should continue to be submitted to Medicare Part B.

All claims submitted will need to use the product NDC and quantity/day supply requested. (50 strips = quantity or 50).

For pharmacy providers that also have a DME provider number, please ensure that you are submitting the claim using the pharmacy provider ID. Claims for these products billed using the DME provider number will be denied.

For blood glucose testing supplies and insulin syringes:
An automated prior authorization process will look for insulin and/or oral diabetic medications in the member’s claims history. For pregnant members, it will look for a diagnosis of gestational diabetes. If the medication or diagnosis is not found in claims history or if the quantity submitted exceeds the maximum allowed, the claim will deny for prior authorization. The prior authorization form can be found on the OHCA website at www.okhca.org/rxforms (PHARM-35). 

If you have new orders for insulin or oral medications and supplies, submit the medication claims first, then submit the claim for the supplies. 

For Continuous Glucose Monitors (CGM):
The CGM systems will require prior authorization (PA). The prior authorization form can be found on the OHCA website at www.okhca.org/rxforms (PHARM-139). The following coverage criteria will apply:

Initial Request
  • Children less than 21 years old with a medically documented diagnosis of Type 1 diabetes mellitus (T1DM); OR
  • Pregnant women with a medically documented diagnosis of T1DM; OR
  • Additional SoonerCare members may be approved for CGM use based on the following:
    • Medically documented diagnosis meeting the criteria of American Diabetes Association (ADA) Standards of Medical Care in Diabetes:
      • Children less than 21 years old with Type 2 diabetes mellitus (T2DM), OR
      • Pregnancy women with gestational diabetes; OR
      • Adults 21 years old and above with T1DM or T2DM; AND
    • Member has been using self-monitoring blood glucose (SMBG; finger sticks) and performing frequent testing (≥4/day);  AND
    • Member is insulin-treated with multiple daily injections (≥3/day) or using insulin pump therapy; AND
    • Member’s insulin treatment regimen requires frequent adjustment by the member or provider on the basis of SMBG or CGM testing results; AND
    • Documentation must include recent history (within the past 6 months) of two (2) or more Level 2 [glucose <54 mg/dL (3.0mmol/L) hypoglycemic] or one (1) Level 3 (severe event characterized by altered mental and/or physical status requiring assistance as a result of hypoglycemia or ketoacidosis, hyperglycemia) episodes in spite of appropriate therapy; AND
    • Within six (6) months prior to ordering the CGM, the treating practitioner has an in-person or telehealth visit with the member and/or family to evaluate their diabetes control and determined that criteria above are met; AND
    • Member and/or family member has participated in age appropriate diabetes education, training, and support prior to beginning CGM.
All requests
  • Age appropriate CGM system based on FDA approval of the continuous glucose monitoring (CGM) system
    •  Children ages 2 and up will be approved for the Dexcom®
    • Children ages 4 and up will be approved for Freestyle Libre®
  • Approvals will be for 1 year duration.
Continuation
  • Member must be seen at least every six (6) months following the initial prescription of the continuous glucose monitoring (CGM), by the CGM prescriber to assess adherence to their CGM regimen and diabetes treatment plan; AND
  • Member must receive ongoing instruction and regular evaluation of technique, results, and their ability to use data from self-monitoring of blood glucose to adjust therapy; AND
  • CGM must be used as close to daily as possible for maximal benefit. Documentation (i.e. trend graphs or CGM reports) must be in the member’s prescriber records demonstrating member’s daily use of the CGM; AND
  • Member must continue to meet initial criteria (including finger stick criteria when CGM is not being utilized when required for initial approval) above in order to be approved for continued use of CGM.
If you have questions about this information or need assistance with a claim, please call the pharmacy help desk at (800) 522-0114, option 4. 

Blood Glucose Meters and Strips

SoonerCare prefers the following brands of diabetic testing meters and strips. All other blood glucose meters and strips will not be covered. Approval may be granted for non-preferred products if the preferred meter is not compatible with the member's insulin pump or the member requires a talking meter.

Glucometer/Test Strips/Lancets:

FreeStyle and Precision blood glucose test strips and meters will no longer be a SoonerCare preferred brand. The preferred brands will be OneTouch and True Metrix test strips and meters. 

Preferred Blood Glucose Monitors

Blood glucose monitors are restricted to one meter per member per year. 

NDC Description

NDC

OneTouch Verio Reflect Meter System

53885-0927-01

OneTouch Verio Flex Meter System

53885-0044-01

OneTouch Verio Meter System

53885-0657-01

OneTouch Ultra 2 Meter System

53885-0046-01

OneTouch Verio Flex Meter System

53885-0194-01

OneTouch Verio IQ Meter System

53885-0267-01

OneTouch Ultra 2 Meter System

53885-0448-01

OneTouch UltraMini Meter System

53885-0208-01
ReliOn True Metrix Air Glucose Meter

56151-1491-02

True Metrix Air Glucose Meter   

56151-1490-02

True Metrix Glucose Meter

56151-1470-02

True Metrix Glucose Meter

56151-1470-04

 

Preferred Blood Glucose Testing Strips  

NDC Description

NDC

OneTouch Verio Test Strips 25ct

53885-0270-25

OneTouch Verio Test Strips 50ct

53885-0271-50

OneTouch Verio Test Strips 100ct

53885-0272-10

OneTouch Ultra Test Strips 25ct

53885-0994-25

OneTouch Ultra Test Strips 50ct

53885-0244-50

OneTouch Ultra Test Strips 100ct

53885-0245-10

True Metrix Glucose Test Strips 100ct

56151-1460-01

True Metrix Glucose Test Strips 50ct

56151-1460-04

ReliOn True Metrix Glucose Test Strips 100ct

56151-1461-01

ReliOn True Metrix Glucose Test Strips 50ct

56151-1461-04

Miscellaneous Supplies

Please keep in mind supplies used for insulin pumps will not be covered through the pharmacy POS. Please continue to bill those through DME.

SoonerCare covers most brands of the following diabetic testing supplies within the pharmacy benefit. There are no preferred products and products are reimbursed at the Medicare Competitive Bid Rate. Covered NDCs can be downloaded as a pdf here

Supply Item

Maximum Quantity

Control Solution

One bottle per year

Insulin Syringes        

200 per month

Ketone Urine Strips    

100 per month

Lancing Device

One device per year

Lancets

200 lancets per month

Pen Needles

200 per month

 

Preferred Continuous Glucose Monitors (CGM)

NDC Description

NDC

FreeStyle Libre Sensor Kit

57599-0000-19

FreeStyle Libre Reader

57599-0000-21

FreeStyle Libre 14 Day Sensor Kit

57599-0001-01

FreeStyle Libre 14 Day Reader

57599-0002-00

FreeStyle Libre 2 Reader     

57599-0803-00

FreeStyle Libre 2 Sensor         

57599-0800-00

Dexcom G6 Transmitter

08627-0016-01

Dexcom G6 Sensor

08627-0053-03

Dexcom G6 Receiver

08627-0091-11

 

 

Last Modified on Mar 25, 2022
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