Limited Coverage Medical Supplies - Blood Glucose Test Strips

Special Authority Criteria

Approval Period

For patients requiring 100 additional blood glucose test strips AND who are not using insulin AND are 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)