Primary navigation

    Diabetic Testing Supplies

    Drug - Diabetic Testing Supplies

    April 2020

    Therapeutic area - Diabetic Testing Supplies

    Approval criteria for nonpreferred products

    • Patient is legally blind or has reduced visual acuity so that they are unable to see the numbers on ALL of the preferred products and the requested product has a feature that enables the patient to use the product that is not available on any of the preferred products. The patient (not a caregiver) must be the one using the products OR
    • Patient is currently using an insulin pump that needs specific product compatibility to accurately dose insulin OR
    • Preferred product is not compatible with insulin pump recipient is using OR
    • Recipient is unable to change to a preferred product combination (e.g., meter and strip) due to a cognitive or developmental disability OR
    • Changing to a preferred product combination (e.g., meter and strip) would create undue hardship for the recipient

    Quantity limit

    Quantity limit overrides for test strips will be approved if:

    • The patient has been stabilized on the current regimen. Stabilization on the current regimen is defined as having the prescription filled at least two times in the past 90 days AND
    • MHCP (either FFS or Managed Care) has paid for the previous two fills in excess of the quantity limit AND
    • Approved quantity will be the same as in previous fill(s)

    OR

    • The patient has a diagnosis of type 1 diabetes AND
    • Approved quantity will not exceed 300 or 306 strips per 30 days (depending on package size)

    OR

    • The patient has a diagnosis of type 2 diabetes AND
    • The patient needs to test more than 3 times per day due to any one of the following:
      • The patient has not been prescribed test strips previously OR
      • The patient’s diabetes medication regimen (including insulin) is undergoing changes AND
    • Approved quantity will not exceed 200 or 204 strips per 30 days (depending on package size)

    Quantity limit overrides are not available for glucose monitors, continuous glucose monitors, transmitters or sensors.

    Patient with defective product should contact the manufacturer for assistance:

    Accu-Chek Customer Service: 800-858-8072
    Contour Customer Service: 800-401-8440
    Dexcom Customer Service:  844-607-8398
    Freestyle Libre Customer Service:  855-632-8658

    Preferred blood glucose monitors

    Product (limit of one meter per year) NDC
    Accu-Chek Aviva Plus 65702072310
    65702010110
    Accu-Chek Guide 65702072910
    65702061710
    Accu-Chek Guide Me 65702073110
    Accu-Chek Nano SmartView 65702048310
    Contour 00193718901
    00193954501
    Contour Next 00193737701
    Contour Next EZ 00193725201
    00193962801
    Contour Next ONE 00193781801


    Preferred blood glucose testing strips

    Product (limit of 100* strips per month) NDC
    Accu-Chek Aviva Plus Test Strip 65702040710
    65702040810
    Accu-Chek Compact Plus 50924098850
    50924088401
    Accu-Chek Guide 65702071110 
    65702071210
    Accu-Chek Smartview Test Strip 65702049210
    65702049310
    Contour Test Strips 00193707025
    00193709021
    00193708050
    Contour Next Test Strips 00193731025
    00193731150
    00193731221

    *100 or 102 depending on the package size

    Preferred continuous glucose monitors

    Product (limit of one receiver or reader per 365 days) NDC
    Dexcom G6 Receiver 08627009111
    Freestyle Libre 14 Day Reader 57599000200

    Preferred transmitters and sensors

    Product (quantity limit applies) NDC
    Dexcom G6 transmitter (1 every 90 days) 08627001601
    Dexcom G6 Sensor 3 Pack (1 every 30 days) 08627005303
    Freestyle Libre 14 Day Sensor (2 every 28 days) 57599000101

    Questions?

    MHCP Provider Call Center 651-431-2700 or 800-366-5411

    back to top