Diabetic Test Strips .com

Texas Prior Authorization Program Clinical Criteria

Drug/Drug Class

Diabetic Test Strips

This edit was recommended for review by an MCO to ensure appropriate prescribing of diabetic test strips.

Clinical Criteria Information Included in this Document Diabetic Test Strips ? Drugs requiring prior authorization: the list of drugs requiring prior authorization for this clinical criteria ? Prior authorization criteria logic: a description of how the prior authorization request will be evaluated against the clinical criteria rules ? Logic diagram: a visual depiction of the clinical criteria logic ? Supporting tables: a collection of information associated with the steps within the criteria (diagnosis codes, procedure codes, and therapy codes); provided when applicable ? References: clinical publications and sources relevant to this clinical criteria Note: Click the hyperlink to navigate directly to that section

Revision Notes Updated to include formulary statement (The listed GCNS may not be an indication of TX Medicaid Formulary coverage. To learn the current formulary coverage, visit formulary/formulary-search.) on each `Drug Requiring PA' table

March 27, 2019

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Texas Prior Authorization Program Clinical Criteria

Diabetic Test Strips

Diabetic Test Strips

Drugs Requiring Prior Authorization

The listed GCNS may not be an indication of TX Medicaid Formulary coverage. To learn the current formulary coverage, visit formulary/formulary-search.

Drugs Requiring Prior Authorization

Label Name

GCN

DIABETIC TEST STRIPS

25200

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Texas Prior Authorization Program Clinical Criteria

Diabetic Test Strips

Diabetic Test Strips

Clinical Criteria Logic

1. Does the client have one claim for diabetic test strips more than 90 days ago? [ ] Yes (Go to #2) [ ] No (Approve ? 90 days)

2. Does the client have a diagnosis of Type 1, 2 or pre-diabetes in the last 730 days? [ ] Yes (Approve ? 365 days) [ ] No (Go to #3)

3. Does the client have a diagnosis of gestational diabetes in the last 365 days? [ ] Yes (Approve ? 365 days) [ ] No (Go to #4)

4. Does the client have 1 claim for an agent used to treat diabetes in the last 730 days? [ ] Yes (Approve ? 365 days) [ ] No (Go to #5)

5. Does the client have one claim for a medication that can affect blood sugar levels (antipsychotic agents, oral glucocorticoid agents, etc.) or infers pregnancy in the last 365 days? [ ] Yes (Approve ? 365 days) [ ] No (Deny)

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Texas Prior Authorization Program Clinical Criteria

Diabetic Test Strips

Diabetic Test Strips

Step 1

Does the client have 1 No claim for diabetic test strips more than 90

days ago?

Clinical Criteria Logic Diagram

Approve Request (365 days)

Yes

Step 2

Does the client have a Yes diagnosis of type 1, 2 or pre-diabetes in the

last 730 days?

Approve Request (365 days)

No

Step 3

Does the client have a Yes diagnosis of

gestational diabetes in the last 365 days?

Approve Request (365 days)

No

Step 4

Does the client have 1 Yes claim for an agent

used to treat diabetes in the last 730 days?

Approve Request (365 days)

No

Step 5

Does the client have 1 claim for a medication Yes that can affect blood sugar levels or infers pregnancy in the last

365 days?

Approve Request (365 days)

No

Deny Request

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Texas Prior Authorization Program Clinical Criteria

Diabetic Test Strips

Diabetic Test Strips

ICD-10 Code E1010 E1011 E1021 E1022 E1029 E10311 E10319 E103211 E103212 E103213 E103219 E103291 E103292 E103293 E103299 E103311 E103312 E103313 E103319 E103391

Clinical Criteria Supporting Tables

Step 1 (diagnosis of type 1, 2 or pre-diabetes) Required diagnosis: 1

Look back timeframe: 730 days

Description

TYPE 1 DIABETES MELLITUS WITH KETOACIDOSIS WITHOUT COMA

TYPE 1 DIABETES MELLITUS WITH KETOACIDOSIS WITH COMA

TYPE 1 DIABETES MELLITUS WITH DIABETIC NEPHROPATHY

TYPE 1 DIABETES MELLITUS WITH DIABETIC CHRONIC KIDNEY DISEASE TYPE 1 DIABETES MELLITUS WITH OTHER DIABETIC KIDNEY COMPLICATION TYPE 1 DIABETES MELLITUS WITH UNSPECIFIED DIABETIC RETINOPATHY WITH MACULAR EDEMA TYPE 1 DIABETES MELLITUS WITH UNSPECIFIED DIABETIC RETINOPATHY WITHOUT MACULAR EDEMA TYPE 1 DIABETES MELLITUS WITH MILD NONPROLIFERATIVE DIABETIC RETINOPATHY WITH MACULAR EDEMA, RIGHT EYE TYPE 1 DIABETES MELLITUS WITH MILD NONPROLIFERATIVE DIABETIC RETINOPATHY WITH MACULAR EDEMA, LEFT EYE TYPE 1 DIABETES MELLITUS WITH MILD NONPROLIFERATIVE DIABETIC RETINOPATHY WITH MACULAR EDEMA, BILATERAL TYPE 1 DIABETES MELLITUS WITH MILD NONPROLIFERATIVE DIABETIC RETINOPATHY WITH MACULAR EDEMA, UNSPECIFIED EYE TYPE 1 DIABETES MELLITUS WITH MILD NONPROLIFERATIVE DIABETIC RETINOPATHY WITHOUT MACULAR EDEMA, RIGHT EYE TYPE 1 DIABETES MELLITUS WITH MILD NONPROLIFERATIVE DIABETIC RETINOPATHY WITHOUT MACULAR EDEMA, LEFT EYE TYPE 1 DIABETES MELLITUS WITH MILD NONPROLIFERATIVE DIABETIC RETINOPATHY WITHOUT MACULAR EDEMA, BILATERAL TYPE 1 DIABETES MELLITUS WITH MILD NONPROLIFERATIVE DIABETIC RETINOPATHY WITHOUT MACULAR EDEMA, UNSPECIFIED EYE TYPE 1 DIABETES MELLITUS WITH MODERATE NONPROLIFERATIVE DIABETIC RETINOPATHY WITH MACULAR EDEMA, RIGHT EYE TYPE 1 DIABETES MELLITUS WITH MODERATE NONPROLIFERATIVE DIABETIC RETINOPATHY WITH MACULAR EDEMA, LEFT EYE TYPE 1 DIABETES MELLITUS WITH MODERATE NONPROLIFERATIVE DIABETIC RETINOPATHY WITH MACULAR EDEMA, BILATERAL TYPE 1 DIABETES MELLITUS WITH MODERATE NONPROLIFERATIVE DIABETIC RETINOPATHY WITH MACULAR EDEMA, UNSPECIFIED EYE TYPE 1 DIABETES MELLITUS WITH MODERATE NONPROLIFERATIVE DIABETIC RETINOPATHY WITHOUT MACULAR EDEMA, RIGHT EYE

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