Non-Formulary Test Strips, Form

Blood glucose test strips are used with blood glucose meters to monitor blood glucose levels. Prior authorization is required for non-formulary blood glucose test strips. FDA Approved Indication(s) Blood glucose test strips are indicated for use in patients with diabetes mellitus to monitor blood glucose levels. Policy/Criteria Provider must submit documentation (such as office chart notes, lab results or other clinical information) supporting that member has met all approval criteria.
It is the policy of health plans affiliated with Centene Corporation® that non-formulary blood glucose test strips are medically necessary when the following criteria are met:
I. Initial Approval Criteria A. Request for Non-Formulary Test Strips:

1. Provider submits a letter of medical necessity detailing why current formulary products cannot be used (e.g., dexterity impairment, use of an insulin pump requiring specific test strips). Approval duration: 12 months
   B. Other diagnoses/indications: Not applicable II. Continued Therapy A. Request for Non-Formulary Test Strips:

2. Member meets one of the following (a or b): a. Currently receiving prescribed product via Centene benefit or member has previously met initial approval criteria; b. Member is currently receiving prescribed product and is enrolled in a state and product with continuity of care regulations (refer to state specific addendums for CC.PHARM.03A and CC.PHARM.03B). Approval duration: 12 months
   B. Other diagnoses/indications: Not applicable III. Diagnoses/Indications for which coverage is NOT authorized: Not applicable Page 1 of 3

   CLINICAL POLICY Non-Formulary Test Strips IV. Appendices/General Information Appendix A: Abbreviation/Acronym Key FDA: Food and Drug Administration Appendix B: Therapeutic Alternatives Not applicable Appendix C: Contraindications/Boxed Warnings None reported V. Dosage and Administration
   Usage regimen is individualized based on patient-specific goals.
   VI. Product Availability
   Test strip packaging varies by product and manufacturer. VII.