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Glucose Test Strips and Meters Step Therapy Program Summary

Policy Number: PH-91042

For Commercial, Blue Partner, GenPlus and Health Insurance Marketplace formularies preferred products are Ascensia and Lifescan products.               

POLICY REVIEW CYCLE

Effective Date

Date of Origin   

07-01-2024           

FDA LABELED INDICATIONS AND DOSAGE

Agent(s)

FDA Indication(s)

Notes

Ref#

Accu-Chek® products

(Blood glucose test strip, Blood glucose test meter)

NOTE: This table is not inclusive of all available diabetic test strips

1

Advocate® products

(Blood glucose test strip, Blood glucose test meter)

NOTE: This table is not inclusive of all available diabetic test strips

1

CareSens® products

(Blood glucose test strip, Blood glucose test meter)

NOTE: This table is not inclusive of all available diabetic test strips

1

Choice® products

(Blood glucose test strip, Blood glucose test meter)

NOTE: This table is not inclusive of all available diabetic test strips

1

Contour® products

(Blood glucose test strip, Blood glucose test meter)

NOTE: This table is not inclusive of all available diabetic test strips

1

CVS® products

(Blood glucose test strip, Blood glucose test meter)

NOTE: This table is not inclusive of all available diabetic test strips

1

Diathrive® products

(Blood glucose test strip, Blood glucose test meter)

NOTE: This table is not inclusive of all available diabetic test strips

1

EasyGluco® products

(Blood glucose test strip, Blood glucose test meter)

NOTE: This table is not inclusive of all available diabetic test strips

1

Easymax® products

(Blood glucose test strip, Blood glucose test meter)

NOTE: This table is not inclusive of all available diabetic test strips

1

Embrace® products

(Blood glucose test strip, Blood glucose test meter)

NOTE: This table is not inclusive of all available diabetic test strips

1

Fifty50® products

(Blood glucose test strip, Blood glucose test meter)

NOTE: This table is not inclusive of all available diabetic test strips

1

Fora® products

(Blood glucose test strip, Blood glucose test meter)

NOTE: This table is not inclusive of all available diabetic test strips

1

FortisCare® products

(Blood glucose test strip, Blood glucose test meter)

NOTE: This table is not inclusive of all available diabetic test strips

1

Freestyle® products

(Blood glucose test strip, Blood glucose test meter)

NOTE: This table is not inclusive of all available diabetic test strips

1

GHT® Blood Glucose products

(Blood glucose test strip, Blood glucose test meter)

NOTE: This table is not inclusive of all available diabetic test strips

1

Glucocard® products

(Blood glucose test strip, Blood glucose test meter)

NOTE: This table is not inclusive of all available diabetic test strips

1

iGlucose® products

(Blood glucose test strip, Blood glucose test meter)

NOTE: This table is not inclusive of all available diabetic test strips

Infinity® products

(Blood glucose test strip, Blood glucose test meter)

NOTE: This table is not inclusive of all available diabetic test strips

1

MyGlucoHealth® products

(Blood glucose test strip, Blood glucose test meter)

NOTE: This table is not inclusive of all available diabetic test strips

1

Nova Max® products

(Blood glucose test strip, Blood glucose test meter)

NOTE: This table is not inclusive of all available diabetic test strips

1

OneTouch® products

(Blood glucose test strip, Blood glucose test meter)

NOTE: This table is not inclusive of all available diabetic test strips

1

POGO Automatic® products

(Blood glucose test strip, Blood glucose test meter)

NOTE: This table is not inclusive of all available diabetic test strips

1

Precision® products

(Blood glucose test strip, Blood glucose test meter)

NOTE: This table is not inclusive of all available diabetic test strips

1

Prodigy® products

(Blood glucose test strip, Blood glucose test meter)

NOTE: This table is not inclusive of all available diabetic test strips

1

ReliOn® products

(Blood glucose test strip, Blood glucose test meter)

NOTE: This table is not inclusive of all available diabetic test strips

1

Sidekick® products

(Blood glucose test strip, Blood glucose test meter)

NOTE: This table is not inclusive of all available diabetic test strips

1

Smart® Gluco-Monitoring poducts

(Blood glucose test strip, Blood glucose test meter)

NOTE: This table is not inclusive of all available diabetic test strips

1

Telcare® products

(Blood glucose test strip, Blood glucose test meter)

NOTE: This table is not inclusive of all available diabetic test strips

1

Verasens® products

(Blood glucose test strip, Blood glucose test meter)

NOTE: This table is not inclusive of all available diabetic test strips

1

See package insert for FDA prescribing information:  https://dailymed.nlm.nih.gov/dailymed/index.cfm

CLINICAL RATIONALE

Glucose Test Strips and Meters

Glucose Test Strips and appropriate meters are indicated to be used for quantitatively measuring glucose in indicated blood samples. Strips and associated meters are intended for use outside the body by people with diabetes for self-monitoring of blood glucose at home and healthcare professionals in the clinical setting, as an aid to monitor the effectiveness of diabetes control.(1) There are many choices of meters and test strips to choose from. Individuals should choose the device based on ease of use, cost and insurance coverage, information retrieval, flexibility.(1)

The evidence is insufficient regarding when to prescribe blood glucose monitors (BGM) and how often testing is needed for insulin-treated people with diabetes who do not use intensive insulin regimens, such as those with type 2 diabetes using basal insulin with or without oral agents and/or non-insulin injectables. In people with type 2 diabetes not using insulin, routine glucose monitoring may be of limited additional clinical benefit. For some individuals, glucose monitoring can provide insight into the impact of nutrition, physical activity, and medication management on glucose levels. Glucose monitoring may also be useful in assessing hypoglycemia, glucose levels during intercurrent illness, or discrepancies between measured A1C and glucose levels when there is concern an A1C result may not be reliable in specific individuals. For patients using basal insulin, assessing fasting glucose with blood glucose monitoring to inform dose adjustments to achieve blood glucose targets results in lower A1C. For many individuals on intensive insulin regimens using BGM, this requires checking up to 6-10 times daily.(2)

REFERENCES

Number

Reference

1

American Diabetes Association Consumer Guide. Meters. https://consumerguide.diabetes.org/collections/meters.

2

American Diabetes Association Professional Practice Committee; 7. Diabetes Technology: Standards of Care in Diabetes—2024. Diabetes Care 1 January 2024; 47 (Supplement_1): S126–S144. https://doi.org/10.2337/dc24-S007.

POLICY AGENT SUMMARY STEP THERAPY

Target Brand Agent Name(s)

Target Generic Agent Name(s)

Strength

Targeted MSC

Available MSC

Final Age Limit

Preferred Status

*blood glucose meter disposable device with test strips***

M ; N ; O ; Y

N

*Blood Glucose Meter Disposable Device with Test Strips***

M ; N ; O ; Y

N

*blood glucose monitor kit w/ monitor device & digital app** ; *blood glucose monitor kit w/ wellness device & digital app* ; *blood glucose monitoring kit w/ device*** ; *blood glucose monitoring kit***

  ; w/ Well Device  ; w/Device

M ; N ; O ; Y

N

*blood glucose monitoring devices***

M ; N ; O ; Y

N

glucose blood test automatic cartridge

M ; N ; O ; Y

N

glucose blood test strip

M ; N ; O ; Y

N

CLIENT SUMMARY – STEP THERAPY

Target Brand Agent Name(s)

Target Generic Agent Name(s)

Strength

Client Formulary

*Blood Glucose Meter Disposable Device with Test Strips***

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace

*blood glucose meter disposable device with test strips***

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace

*blood glucose monitor kit w/ monitor device & digital app** ; *blood glucose monitor kit w/ wellness device & digital app* ; *blood glucose monitoring kit w/ device*** ; *blood glucose monitoring kit***

  ; w/ Well Device  ; w/Device

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace

*blood glucose monitoring devices***

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace

glucose blood test automatic cartridge

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace

glucose blood test strip

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace

STEP THERAPY CLINICAL CRITERIA FOR APPROVAL

Module

Clinical Criteria for Approval

TARGET AGENT(S)

PREREQUISITE AGENTS

Non-preferred Glucose Cartridges, Test Strips, or All-In-One Glucose Meter Systems

Ascensia and Lifescan products

A nonpreferred glucose cartridge, test strip, or all-in-one glucose meter system product will be approved when ONE of the following is met:

  1. The patient has a medication history of use in the past 90 days that includes use of any preferred glucose cartridge, test strip, or all-in-one meter system OR
  2. The patient has ONE of the following:
    1. Visual impairment OR
    2. An insulin pump OR continuous glucose monitor that is not accommodated with a preferred glucose cartridge, test strip, or all-in-one glucose meter system OR
    3. A physical or a mental disability

Length of Approval: 12 months

*Step therapy requirement may not apply if a prior health plan paid for the medication - documentation of a paid claim may be required.

This pharmacy policy is not an authorization, certification, explanation of benefits or a contract. Eligibility and benefits are determined on a case-by-case basis according to the terms of the member’s plan in effect as of the date services are rendered. All pharmacy policies are based on (i) information in FDA approved package inserts (and black box warning, alerts, or other information disseminated by the FDA as applicable); (ii) research of current medical and pharmacy literature; and/or (iii) review of common medical practices in the treatment and diagnosis of disease as of the date hereof. Physicians and other providers are solely responsible for all aspects of medical care and treatment, including the type, quality, and levels of care and treatment.

The purpose of Blue Cross and Blue Shield of Alabama’s pharmacy policies are to provide a guide to coverage. Pharmacy policies are not intended to dictate to physicians how to practice medicine. Physicians should exercise their medical judgment in providing the care they feel is most appropriate for their patients.

Neither this policy, nor the successful adjudication of a pharmacy claim, is guarantee of payment.

ALBP _  Commercial _ CSReg _ Glucose_Test_Strips_and_Meters_ST _ProgSum_ 07-01-2024  _ © Copyright Prime Therapeutics LLC. May 2024 All Rights Reserved