Freestyle Libre — Blue Cross Blue Shield of Texas

diabetes mellitus

Initial criteria

One of the following must be met:
A. Continuation of therapy: prescriber states patient has been treated with the requested agent (not started on samples) 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 manufacturer recommendations for requested indication OR B. There is information supporting use of the product for this age

Continuation of therapy may be approved when 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