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The Policy VaultThe Policy Vault

Freestyle Libre 2 — Blue Cross Blue Shield of Illinois

diabetes mellitus

Initial criteria

  • Target Agent(s) will be approved when ONE of the following is met:
  • A. The requested agent is eligible for continuation of therapy AND the following:
  • 1. 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
  • B. ALL of the following:
  • 1. The patient has diabetes mellitus AND
  • 2. ONE of the following:
  • A. The patient has a medication history of use in the past 90 days to ONE insulin containing agent [chart notes required] OR
  • B. The patient has a disability that requires use of a continuous blood glucose monitor OR
  • C. The patient has recurring episodes of hypoglycemia AND
  • 3. ONE of the following:
  • A. The patient’s age is within the manufacturer recommendations for the requested indication for the requested product OR
  • B. There is information in support of using the requested product for the patient’s age
  • Additionally, the requested agent will be approved when:
  • 1. The member resides in Ohio AND
  • 2. The plan is Fully Insured or HIM Shop (SG) AND BOTH of the following:
  • A. The patient does NOT have any FDA labeled contraindications to the requested agent AND
  • B. ONE of the following:
  • 1. The patient has another FDA labeled indication for the requested agent and route of administration OR
  • 2. The patient has another indication that is supported in compendia for the requested agent and route of administration OR
  • 3. The prescriber has submitted TWO articles from major peer-reviewed professional medical journals supporting the proposed use(s) as generally safe and effective (randomized, double-blind, placebo-controlled clinical trials; case studies not accepted)

Reauthorization criteria

  • The requested agent is eligible for continuation of therapy when:
  • 1. The prescriber states the patient has been treated with the requested agent within the past 90 days AND is at risk if therapy is changed.

Approval duration

12 months