Freestyle Libre 3 — Blue Cross Blue Shield of New Mexico

Diabetes mellitus

Initial criteria

ONE of the following:
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

Continuation of therapy: prescriber states the patient has been treated with the requested agent within the past 90 days and is at risk if therapy is changed

12 months