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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)


  • 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)


  • 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
Accu-Chek Guide 65702072910
Accu-Chek Guide Me 65702073110
Accu-Chek Nano SmartView 65702048310
Contour 00193718901
Contour Next 00193737701
Contour Next EZ 00193725201
Contour Next ONE 00193781801

Preferred blood glucose testing strips

Product (limit of 100* strips per month) NDC
Accu-Chek Aviva Plus Test Strip 65702040710
Accu-Chek Compact Plus 50924098850
Accu-Chek Guide 65702071110 
Accu-Chek Smartview Test Strip 65702049210
Contour Test Strips 00193707025
Contour Next Test Strips 00193731025

*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


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

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