Dexcom G6 — Blue Cross Blue Shield of Oklahoma

Initial criteria

• ONE of the following: (A) Continuation of therapy AND prescriber states the patient has been treated with the requested agent within the past 90 days (starting on samples is not approvable) 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 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.

Reauthorization criteria

• 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