Freestyle Libre — Blue Cross Blue Shield of Alabama
diabetes management requiring continuous glucose monitoring
Preferred products
- Freestyle Libre
- Freestyle Libre 2
- Freestyle Libre 3
- Dexcom G6
- Dexcom G7
Initial criteria
- The requested agent will be approved when ONE of the following is met:
- - The requested agent is eligible for continuation of therapy AND ONE of the following:
- • The patient has been treated with the requested agent (starting on samples is not approvable) within the past 90 days OR
- • The prescriber states the patient has been treated with the requested agent (starting on samples is not approvable) within the past 90 days AND is at risk if therapy is changed OR
- • The patient has a medication history of use within the past 90 days to ONE prerequisite agent
Approval duration
12 months