Freestyle Libre — Blue Cross Blue Shield of Montana

Initial criteria

• Agent will be approved when ONE of the following is met:
• A. Continuation of therapy: prescriber states patient has been treated with the requested agent (starting on samples not approvable) within the past 90 days AND is at risk if therapy is changed OR
• B. ALL of the following:
• 1. Patient has diabetes mellitus AND
• 2. ONE of the following:
• A. Patient has a medication history of use in the past 90 days to ONE insulin containing agent [chart notes required] OR
• B. Patient has a disability that requires use of a continuous blood glucose monitor OR
• C. Patient has recurring episodes of hypoglycemia AND
• 3. ONE of the following:
• A. Patient’s age is within the manufacturer recommendations for the requested indication for the requested product OR
• B. Information supports use of the requested product for the patient’s age
• Additionally, approval may be granted when ALL of the following are met:
• 1. Member resides in Ohio AND
• 2. Plan is Fully Insured or HIM Shop (SG) AND BOTH of the following:
• A. Patient does NOT have any FDA labeled contraindications to the requested agent AND
• B. ONE of the following:
• 1. Patient has another FDA labeled indication for the requested agent and route of administration OR
• 2. Patient has another indication that is supported in compendia for the requested agent and route of administration OR
• 3. Prescriber submitted TWO articles from major peer-reviewed professional medical journals supporting the proposed use(s) as generally safe and effective (case studies not acceptable).

Reauthorization criteria

• Continuation of therapy when prescriber states 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