Limited coverage - additional blood glucose test strips

Last updated: October 24, 2022

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

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

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)