Testing Supplies for Diabetes

Claims for the preferred blood glucose testing supplies and CGM will not count against the members monthly script limit. These products will also be available with no copay.

Supplies for insulin pumps will continue to be billed through the DME process.

Claims for Medicaid/Medicare dual eligible members are not affected by these changes and should continue to be submitted to Medicare Part B.

All claims submitted will need to use the product NDC and quantity/day supply requested. (50 strips = quantity or 50). 

For pharmacy providers that also have a DME provider number, please ensure that you are submitting the claim using the pharmacy provider ID. Claims for these products billed using the DME provider number will be denied.

For blood glucose testing supplies and insulin syringes: 

• An automated prior authorization process will look for insulin and/or oral diabetic medications in the member’s claims history. 
• For pregnant members, it will look for a diagnosis of gestational diabetes. If the medication or diagnosis is not found in claims history or if the quantity submitted exceeds the maximum allowed, the claim will deny prior authorization.
• The PHARM-35 prior authorization form can be found on the OHCA website at www.okhca.org/rxforms. 

If you have new orders for insulin or oral medications and supplies, submit the medication claims first, then submit the claim for the supplies. 

For Continuous Glucose Monitors (CGM): 
The CGM systems will require prior authorization (PA). The PHARM-139 prior authorization form can be found on the OHCA website at www.okhca.org/rxforms. The following coverage criteria will apply:

• Members with a medically documented diagnosis of diabetes mellitus meeting the criteria of American Diabetes Association Standards of Medical Care in Diabetes; AND
• The member is insulin treated*; OR 
• Additional SoonerCare members may be approved for CGM use based on the following:
  • The member is 20 years of age or under and has problematic hypoglycemia with documentation of at least one of the criteria below:
    • Recurrent of two (2) or more Level 2 events [glucose <54 mg/dL (3.0mmol/L) hypoglycemic] that persist despite multiple attempts to adjust medication(s) and/or modify the diabetes treatment plan; OR
    • A History of one (1) Level 3 event characterized by altered mental and/or physical status requiring third-party assistance for treatment of hypoglycemia; AND 
    • Within six (6) months prior to ordering the CGM, the treating practitioner has an in-person or telehealth visit with the member and/or family to evaluate their diabetes control and determined that criteria above are met; AND
    • Member and/or family member has participated in age-appropriate diabetes education, training, and support prior to beginning CGM.

*Members with diabetes that have a recent insulin claim do not require manual prior authorization paperwork as the CGM supplies will automatically prior authorize through the pharmacy point of sale system.

• Age-appropriate CGM system based on FDA approval of the continuous glucose monitoring (CGM) system
  • Children ages 2 and up will be approved for the Dexcom®
  • Children ages 4 and up will be approved for Freestyle Libre® 
• Approvals will be for 1 year duration.

• A member must be seen at least every six (6) months following the initial prescription of the continuous glucose monitoring (CGM), by the CGM prescriber to assess adherence to their CGM regimen and diabetes treatment plan; AND
• A member must receive ongoing instruction and regular evaluation of technique, results, and their ability to use data from self-monitoring of blood glucose to adjust therapy; AND
• CGM must be used as close to daily as possible for maximal benefit. Documentation (i.e. trend graphs or CGM reports) must be in the member’s prescriber records demonstrating member’s daily use of the CGM; AND
• A member must continue to meet initial criteria above in order to be approved for continued use of CGM. 
  • CGM PA Form
  • Diabetic Supplies PA Form