HARVARD PILGRIM HEALTH CARE RECOMMENDED MEDICATION REQUEST GUIDELINES
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1 Generic Brand HICL GCN Exception/Other BLOOD SUGAR DIAGNOSTIC DIABETIC TEST STRIPS NOTE: Requests for preferred blood glucose (diabetic) test strips manufactured by Abbott Diabetes Care (such as FreeStyle Lite, FreeStyle Insulinx, Precision Xtra and FreeStyle Precision Neo) do not require prior authorization and will adjudicate at the point of service with only a quantity limit. For quantity limit exceptions on preferred products by Abbott Diabetes, use this guideline (Diabetic Test Strips). All other blood glucose test strips will be considered non-preferred and will require prior authorization. A quantity limit of 204 test strips per 30 days will be applied to all blood glucose test strips (preferred and non-preferred), unless the criteria in this guideline (Diabetic Test Strips) is met for more frequent testing. IMPORTANT NOTE: If the MRF is for a quantity limit override of Abbott test strip 300 strips per 30 days (i.e., the patient is testing more than 10 times per day), please defer to HPHC Pharmacy Services via MedResponse. In instances, where MedResponse functionality is unavailable, please fax the MRF request to HPHC Pharmacy Services at (617) The PAC must then call HPHC Pharmacy Services at (617) to tell an Operations Coordinator that the form is being sent for review. NOTE: To determine if a member is on a closed formulary, check the benefit description associated with the benefit code, if the word 'CLOSED' is in the benefit description then is a closed benefit. GUIDELINES FOR USE 1. Is the request for a quantity limit exception for a preferred product (diabetic test strip) manufactured by Abbott Diabetes Care (such as FreeStyle Lite, FreeStyle Insulinx, Precision Xtra and FreeStyle Precision Neo)? If yes, continue to #2. If no, continue to #6. 2. Is the quantity requested greater than 300 strips per 30 days (i.e., the patient is testing more than 10 times per day)? If yes, defer to HPHC. (NOTE: If MedResponse functionality is unavailable, please fax the MRF to HPHC Pharmacy Services at (617) The PAC must then call HPHC Pharmacy Services at (617) to tell an Operations Coordinator that the form is being sent for review.) If no, continue to #3.
2 3. Is the quantity requested greater than the quantity limit of 204 strips per 30 days (i.e., the patient is testing more than 6 times per day)? If yes, continue to #4. If no, PA is not required. Please use status code # Does the patient's refill history (if available) support requested frequency of blood glucose testing? If yes, proceed as follows: For members with an Open or Closed formulary: Approve 12 months by GPID for the quantity requested on the MRF per 30 days. IMPORTANT NOTE: Please enter a MDD (max daily dose) of the number of test strips. Round up the MDD to the nearest factor that will allow a box size of 50 to go through. For example: For 7 strips per day, please enter MDD = 8.4 For 8 strips per day, please enter MDD = 8.4 For 9 strips per day, please enter MDD = 10 approved for a period of 12 months with a quantity limit of ### test strips per 30 days. If no, continue to #5.
3 5. Has the prescriber indicated that the patient requires more frequent testing than 6 times per day for one of the following reasons: Patient has hypoglycemia unawareness Patient has Type 1 DM and uses an insulin pump Patient has Type 1 DM and injecting insulin more than 4 times per day Patient participates in routine exercise/physical activity If yes, proceed as follows: For members with an Open or Closed formulary: Approve 12 months by GPID for the quantity requested on the MRF per 30 days. IMPORTANT NOTE: Please enter with a MDD (max daily dose) of the number of test strips. Round up the MDD to the nearest factor that will allow a box size of 50 to go through. For example: For 7 strips per day, please enter MDD = 8.4 For 8 strips per day, please enter MDD = 8.4 For 9 strips per day, please enter MDD = 10 approved for a period of 12 months with a quantity limit of ### test strips per 30 days. If no, proceed as follows: For members with an Open or Closed formulary: Do not approve. Please use status code #238 and the provided denial text. Please use status code #238 and the following approval language: DENIAL APPROVAL TEXT DENIAL TEXT: Per your health plan's Diabetic Test Strips guideline, are covered with a quantity limit of 204 test strips per 30 days. Quantities over that limit are covered for patients with at least one of the following conditions: hypoglycemia unawareness, type 1 diabetes and uses an insulin pump, type 1 diabetes and injects insulin more than 4 times a day, or participates in routine exercise or physical activity. Your physician did not indicate that you meet one of those following conditions and therefore your request for an increased quantity of test strips was not approved. Please note that preferred products are available with a quantity limit of 204 test strips per 30 days. 6. Does the patient require the use of a non-preferred blood glucose test strip due to significant visual, physical, or functional impairment? If yes, continue to #8. If no, continue to #7.
4 7. Is the patient currently using an insulin pump that is not fully compatible with a preferred blood glucose monitoring system and test strip/disk product (FreeStyle Lite, Precision Xtra, and FreeStyle Precision Neo, FreeStyle Insulinx)? If yes, continue to #8. If no, do not approve. Please use status code #238 and the provided denial text. DENIAL TEXT: Per your health plan's Diabetic Test Strips guideline, this product is only covered for patients that require the use of a non-preferred blood glucose test strip due to significant visual, physical, or functional impairment, or for patients currently using an insulin pump that is not fully compatible with a preferred blood glucose monitoring system and test strip/disk product. Your physician did not indicate that you are using this product due to any of these conditions and therefore your request was not approved. Harvard Pilgrim Health Care's preferred diabetes testing supplies are available from Abbott Diabetes Care. You may obtain a free Abbott glucometer (such as the FreeStyle Lite) from Abbott Diabetes by one of the following options: 1) Call Abbott directly at or 2) Online at or 3) Take a prescription to a contracted pharmacy. 8. Is the quantity requested greater than 300 strips per 30 days (i.e., the patient is testing more than 10 times per day)? If yes, defer to HPHC. (NOTE: If MedResponse functionality is unavailable, please fax the MRF to HPHC Pharmacy Services at (617) The PAC must then call HPHC Pharmacy Services at (617) to tell an Operations Coordinator that the form is being sent for review.) If no, continue to #9.
5 9. Is the quantity requested greater than the quantity limit of 204 strips per 30 days (i.e., the patient is testing more than 6 times per day)? If yes, continue to #10. If no, proceed as follows: For members with an Open formulary: Approve 12 months by GPID. In addition, enter a quantity limit of 204 test strips per 30 days. IMPORTANT NOTE: Please enter with a MDD (max daily dose) of 6.8/day and override the formulary. APPROVAL TEXT: Your request for a non-preferred blood glucose test strip has been approved for a period of 12 months with a quantity limit of 204 test strips per 30 days. For members with a Closed formulary: Approve 12 months by GPID at the appropriate tier listed in the table below. In addition, enter a quantity limit of 204 test strips per 30 days. IMPORTANT NOTE: Please enter with a MDD (max daily dose) of 6.8/day and override the formulary. APPROVAL TEXT: Your request for a non-preferred blood glucose test strip has been approved for a period of 12 months with a quantity limit of 204 test strips per 30 days at your highest cost-share tier. Refer to your Harvard Pilgrim ID card for the amount you pay for drugs on that tier. Benefit Drug Description Exception Tier 3 Tier All non-formulary 3 4 Tier All non-formulary 4 5 Tier All non-formulary 5
6 10. Does the patient's refill history (if available) support requested frequency of blood glucose testing? If yes, proceed as follows: For members with an Open formulary: Approve 12 months by GPID for the quantity requested on the MRF per 30 days. IMPORTANT NOTE: Please enter with a MDD (max daily dose) of the number of test strips and override formulary. Round up the MDD to the nearest factor that will allow a box size of 50 to go through. For example: o For 7 strips per day, please enter MDD = 8.4 o For 8 strips per day, please enter MDD = 8.4 o For 9 strips per day, please enter MDD = 10 APPROVAL TEXT: Your request for a blood glucose test strip has been approved for a period of 12 months with a quantity limit of ### test strips per 30 days. For members with a Closed formulary: Approve 12 months by GPID at the appropriate tier listed in the table below for the quantity requested on the MRF per 30 days. IMPORTANT NOTE: Please enter with a MDD (max daily dose) of the number of test strips and override the formulary. Round up the MDD to the nearest factor that will allow a box size of 50 to go through. For example: o For 7 strips per day, please enter MDD = 8.4 o For 8 strips per day, please enter MDD = 8.4 o For 9 strips per day, please enter MDD = 10 approved for a period of 12 months with a quantity limit of ### test strips per 30 days at your highest cost-share tier. Refer to your Harvard Pilgrim ID card for the amount you pay for drugs on that tier. If no, continue to #11. Benefit Drug Description Exception Tier 3 Tier All non-formulary 3 4 Tier All non-formulary 4 5 Tier All non-formulary 5
7 11. Has the prescriber indicated that the patient requires more frequent testing than 6 times per day for one of the following reasons: Patient has hypoglycemia unawareness Patient has Type 1 DM and uses an insulin pump Patient has Type 1 DM and injecting insulin more than 4 times per day Patient participates in routine exercise/physical activity If yes, proceed as follows: For members with an Open formulary: Approve 12 months by GPID for the quantity requested on the MRF per 30 days. IMPORTANT NOTE: Please enter with a MDD (max daily dose) of the number of test strips and override the formulary. Round up the MDD to the nearest factor that will allow a box size of 50 to go through. For example: o For 7 strips per day, please enter MDD = 8.4 o For 8 strips per day, please enter MDD = 8.4 o For 9 strips per day, please enter MDD = 10 approved for a period of 12 months with a quantity limit of ### test strips per 30 days. For members with a Closed formulary: Approve 12 months by GPID at the appropriate tier listed in the table below for the quantity requested on the MRF per 30 days. IMPORTANT NOTE: Please enter with a MDD (max daily dose) of the number of test strips and override the formulary. Round up the MDD to the nearest factor that will allow a box size of 50 to go through. For example: o For 7 strips per day, please enter MDD = 8.4 o For 8 strips per day, please enter MDD = 8.4 o For 9 strips per day, please enter MDD = 10 approved for a period of 12 months with a quantity limit of ### test strips per 30 days at your highest cost-share tier. Refer to your Harvard Pilgrim ID card for the amount you pay for drugs on that tier. Benefit Drug Description Exception Tier 3 Tier All non-formulary 3 4 Tier All non-formulary 4 5 Tier All non-formulary 5 (Closed formulary approval, continued on next page)
8 If no, proceed as follows: For members with an Open formulary: partially approve for 12 months by GPID. In addition, enter a quantity limit of 204 test strips per 30 days. IMPORTANT NOTE: Please enter with a MDD (max daily dose) of 6.8/day and override the formulary. Please use status code #056 and provide partial approval text: PARTIAL APPROVAL TEXT: Your request for a non-preferred blood glucose test strip has been approved for a period of 12 months with a quantity limit of 204 test strips per 30 days. Per your health plan's Diabetic Test Strips guideline, are covered with a quantity limit of 204 test strips per 30 days. Quantities over that limit are covered for patients with at least one of the following conditions: hypoglycemia unawareness, type 1 diabetes and uses an insulin pump, type 1 diabetes and injects insulin more than 4 times a day, or participates in routine exercise or physical activity. Your physician did not indicate that you meet one of those following conditions and therefore your request for an increased quantity of test strips was not approved. For members with a closed formulary: partially approve for 12 months by GPID at the appropriate tier listed in the table below. In addition, enter a quantity limit of 204 test strips per 30 days. IMPORTANT NOTE: Please enter with a MDD (max daily dose) of 6.8/day and override the formulary. Please use status code #056 and provide partial approval text: PARTIAL APPROVAL TEXT: Your request for a non-preferred blood glucose test strip has been approved for a period of 12 months with a quantity limit of 204 test strips per 30 days at your highest cost-share tier. Refer to your Harvard Pilgrim ID card for the amount you pay for drugs on that tier. Per your health plan's Diabetic Test Strips guideline, are covered with a quantity limit of 204 test strips per 30 days. Quantities over that limit are covered for patients with at least one of the following conditions: hypoglycemia unawareness, type 1 diabetes and uses an insulin pump, type 1 diabetes and injects insulin more than 4 times a day, or participates in routine exercise or physical activity. Your physician did not indicate that you meet one of those following conditions and therefore your request for an increased quantity of test strips was not approved. Benefit Drug Description Exception Tier 3 Tier All non-formulary 3 4 Tier All non-formulary 4 5 Tier All non-formulary 5
9 RATIONALE The intent of this prior authorization is to encourage the use of cost-effective formulary preferred glucose testing strips before considering coverage of non-preferred alternatives. FDA APPROVED INDICATIONS N/A REFERENCES Drug Facts and Comparisons (online version), Blood Glucose Meters. Available at Accessed January 4, American Diabetes Association. Standards of Medical Care in Diabetes Diabetes Care 2011; 34(suppl 1): S11-S61. Created: 01/05/12 Effective: 10/01/16 Client Approval: 08/03/16 P&T Approval: 09/12/16
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