Guardian connect transmitter — Blue Cross Blue Shield of Kansas

Preferred products

• Freestyle libre 14 day
• Freestyle libre 2
• Freestyle libre 3
• Freestyle libre reader
• Guardian real-time replac

Initial criteria

• 1. The requested agent is eligible for continuation of therapy AND ONE of the following: A. The patient has been treated with the requested agent (not including samples) within the past 90 days OR B. The prescriber states the patient has been treated with the requested agent (not including samples) within the past 90 days AND is at risk if therapy is changed.
• OR 2. BOTH of the following: A. The requested agent is not a component of the Eversense, Eversense E3, or Eversense 365 CGM system AND B. ONE of the following:
• 1. Long-term continuous glucose monitoring for diabetic monitoring is requested AND ONE of the following: A. Type 1 diabetes AND ALL: • Patient understands the technology • Patient is motivated to use correctly and consistently • Patient is expected to adhere to a comprehensive diabetes treatment plan supervised by a qualified provider • Patient is capable of recognizing alerts and alarms OR B. Type 2 diabetes AND ALL: • Patient is willing and able to use the device • Patient has adequate medical supervision • ONE of the following: A. Patient has experienced significant hypoglycemia (medical records required) OR B. Patient is currently treated with insulin therapy (medical records required)
• 2. Short-term continuous glucose monitoring for diabetic monitoring is requested AND ONE of the following: A. Type 1 diabetes AND ONE of the following: • Poorly controlled disease defined by ≥1 of: unexplained hypoglycemic episodes, hypoglycemic unawareness, suspected postprandial hyperglycemia, recurrent diabetic ketoacidosis • Need to determine basal insulin level before insulin pump initiation OR B. Type 2 diabetes AND BOTH: • Requires multiple daily doses of insulin (medical records required) • ONE of the following: A. Poorly controlled disease defined by ≥1 of: unexplained hypoglycemic episodes, hypoglycemic unawareness, persistent hyperglycemia, A1c above target B. Need to determine basal insulin levels prior to insulin pump initiation (medical records required)

Reauthorization criteria

• Continuation requests: patient has been treated with the requested agent within the past 90 days or prescriber confirms continued treatment within the past 90 days and continuation is clinically appropriate

Approval duration

12 months