Subject: Diabetic Test Strips Limit 1372-H P04-2026

Policy:

Indications

FDA-approved Indications

N/A

Initial Limit Quantity

Limits should accumulate across all products up to highest quantity listed.

PLEASE NOTE: 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.

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.

Product	1 Month Limit	3 Month Limit
Diabetic Test Strips	150 test strips / 25 days	450 test strips / 75 days

Place of Service:

Outpatient

The above policy is based on the following references:

1. American Diabetes Association Professional Practice Committee 7. Diabetes Technology: Standards of Care in Diabetes - 2026. Diabetes Care 2026;49(Suppl. 1):S150-S165.
2. Weinstock RS, Aleppo G, Bailey TS, et al. The Role of Blood Glucose Monitoring in Diabetes Management. Arlington (VA): American Diabetes Association; October 2020.

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.

May 09, 2026