Limited Coverage Medical Supplies - Blood Glucose Test Strips

Special Authority Criteria

Approval Period

Patient has diabetes, is not on insulin

OR

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

OR

• Acute illness or comorbidities that may impact blood glucose control

OR

• 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)

OR

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

OR

• Gestational diabetes

Not applicable