Limited coverage - additional blood glucose test strips

Last updated: October 24, 2022

Special Authority criteria

Approval period

Patient has diabetes, is not on insulin


Patient has diabetes, is on insulin and is using a continuous glucose monitor (CGM), and is experiencing at least one of the following:

  • Not meeting glycemic targets, as determined by a physician, for 3 months or more


  • Acute illness or comorbidities that may impact blood glucose control


  • Changes in drug therapy that may impact blood glucose control (e.g., starting or stopping hypo- or hyperglycemic inducing medications, or drug-to-drug or drug-to-disease interactions)


  • Occupations where hypoglycemia presents a significant safety risk (e.g., pilots, air traffic controllers, commercial drivers)


  • Gestational diabetes

Not applicable

Practitioner exemptions

  • None

Special notes

Special Authority request form(s)