Subject: Diabetic Test Strips Post Limit PA Policy 1373-J UDR 04-2024
Policy:
FDA-APPROVED INDICATIONS
N/A
COVERAGE CRITERIA
Authorization may be granted for the requested product when the following criteria is met:
• The patient is on an intensive insulin regimen (multiple-dose insulin or insulin pump therapy)
QUANTITY LIMITS APPLY
300 test strips** per 25 days* or 900 test strips** per 75 days*
* The duration of 25 days is used for a 30-day fill period and 75 days is used for a 90-day fill period to allow time for refill processing.
** Since manufacturer package sizes may vary, it is the discretion of the dispensing pharmacy to fill quantities per package size up to these quantity limits. In such cases the filling limit and day supply may be less than what is indicated.
DURATION OF APPROVAL (DOA)
• 1373-J: DOA: 12 months
Place of Service:
Outpatient
The above policy is based on the following references:
- American Diabetes Association Professional Practice Committee 7. Diabetes technology: Standards of Care in Diabetes - 2024. Diabetes Care 2024;47(Suppl. 1):S126-S144.
Copyright Aetna Inc. All rights reserved. Pharmacy Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.
August 29, 2024
