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Table 78: Diabetes Medical Supplies and Emergency Treatments


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Drug Category: Various

Medication Class/Individual Agents: Various

I. Prior-Authorization Requirements

 

Clinical Notes

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

Drug
Notes

dasiglucagon Zegalogue PA  
glucagon auto-injection, prefilled syringe Gvoke PA  
glucagon nasal powder Baqsimi PD test  
glucagon vial Glucagen test  
glucagon vial test  

Please note: In the case where the prior authorization (PA) status column indicates PA, both the brand and generic (if available) require PA. Typically, the generic is preferred when available unless the brand-name drug appears on the MassHealth Brand Name Preferred Over Generic Drug List. In general, when requesting the non-preferred version, whether the brand or generic, the prescriber must provide medical records documenting an inadequate response or adverse reaction to the preferred version, in addition to satisfying the criteria for the drug itself.

 

The following non-drug diabetes medical supplies are covered through the Pharmacy Online Processing System (POPS):

Medical Supplies

  • Alcohol swabs
  • Disposable syringe and needle units
  • Freestyle, Freestyle Lite, FreeStyle Insulinx, and Precision Xtra brand blood glucose testing reagent strips used for the management of diabetes – PA > 100 units/month. All other brands of blood glucose testing reagent strips used for the management of diabetes – PA
  • Lancets
  • Urine glucose testing reagent strips used for the management of diabetes

 

Devices

  • Dexcom G6 and Freestyle Libre continuous glucose monitoring products used for the management of diabetes  PA
  • Insulin cartridge delivery devices, needles, and patch pumps for insulin delivery or other devices for injection of medication, excluding other devices for the continuous administration of insulin (for example, epinephrine auto-injectors)

 

Please see the following link to find out more information regarding the Non-Drug Product List: https://masshealthdruglist.ehs.state.ma.us/MHDL/pubdownloadpdfwelcome.do?docId=8&fileType=PDF.

 
Table Footnotes
PD Preferred Drug. In general, MassHealth requires a trial of the preferred drug or clinical rationale for prescribing a non-preferred drug within a therapeutic class.
 

II. Therapeutic Uses

FDA-approved, for example:

  • Diabetes mellitus

 

Note: The above list may not include all FDA-approved indications.

 

 

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III.  Evaluation Criteria for Approval

Please note: In the case where the prior authorization (PA) status column indicates PA, both the brand and generic (if available) require PA. Typically, the generic is preferred when available unless the brand-name drug appears on the MassHealth Brand Name Preferred Over Generic Drug List. In general, when requesting the non-preferred version, whether the brand or generic, the prescriber must provide medical records documenting an inadequate response or adverse reaction to the preferred version, in addition to satisfying the criteria for the drug itself.

  • All PA requests must include clinical diagnosis, drug name, dose, and frequency.
  • A preferred drug may be designated for this therapeutic class. In general, MassHealth requires a trial of the preferred drug or clinical rationale for prescribing a non-preferred drug within a therapeutic class. Additional information about these agents, including PA requirements and preferred products, can be found within the MassHealth Drug List at www.mass.gov/druglist.
  • For recertification requests, approval may require submission of additional documentation including, but not limited to, documentation of: some or all criteria for the original approval; response to therapy; clinical rationale for continuation of use; status of member’s condition; appropriate diagnosis; appropriate age; appropriate dose, frequency, and duration of use for requested medication; complete treatment plan; current laboratory values; and member’s current weight.
  • Additional criteria may apply, depending upon the member’s condition and requested medication (see below).

  

All requests for blood glucose testing reagent strips at quantities above established quantity limits

  • Documentation of one of the following is required:  
    • for members utilizing a continuous glucose monitoring device, both of the following:
      • medical necessity for increased testing; and
      • treatment plan describing self-testing frequency.
    • for members not utilizing a continuous glucose monitoring device, one of the following:
      • medical necessity for increased testing; or
      • treatment plan describing self-testing frequency.

 

SmartPA: Claims for Freestyle, Freestyle Lite, FreeStyle Insulinx, or Precision Xtra brand blood glucose testing reagent strips for > 100 strips/30 days but ≤ 200 strips/30 days will usually process at the pharmacy without a PA request if the member has a paid MassHealth pharmacy claim for injectable insulin or a prenatal vitamin within the last 90 days. 

  

Dexcom G6, Freestyle Libre 2, Freestyle Libre 14 Day

  • Documentation of all of the following is required:
    • appropriate diagnosis; and
    • member’s current treatment plan involves testing blood glucose at least four times per day; and
    • member is currently receiving multiple daily insulin injections or an insulin pump; and
    • one of the following:
      • A1c ≥ 7% or that does not meet documented target treatment despite diabetic education and adherence to self-monitoring of glucose levels; or
      • frequent hypoglycemia (or nocturnal hypoglycemia); or
      • history of hypoglycemic unawareness; or
      • dawn phenomenon with fasting blood sugars frequently exceeding 200 mg/dL; or
      • history of emergency room visit or hospitalization related to ketoacidosis or hypoglycemia; or
      • use with compatible insulin pump to achieve glycemic control; or
      • pregnancy.

  

FreeStyle Neo

  • Documentation of all of the following is required:
    • documentation that member is using compatible continuous glucose monitoring device; and
    • quantity requested is ≤ 100 units per month.

 

SmartPA:  Claims for Freestyle Neo test strips at less than or equal to 100 strips per 30 days will usually process and pay at the pharmacy, if the member has a claim for Freestyle Libre 2 or Freestyle Libre 14 Day sensors within the last 90 days.† 

 

Gvoke

  • Documentation of all of the following is required:
    • appropriate diagnosis; and
    • one of the following:
      • member is ≥ two years and < four years of age; or
      • inadequate response, adverse reaction or contraindication to Baqsimi.

  

Non-preferred blood glucose testing reagent strips

  • Documentation of all of the following is required:
    • medical necessity for a non-preferred product; and
    • quantity requested is ≤ 100 units per month.

 

SmartPA: Claims for Prodigy brand blood glucose testing reagent strips for ≤ 100 strips/30 days will usually process at the pharmacy without a PA request if the member has a history of MassHealth medical claims for visual impairment. Claims for Prodigy brand blood glucose testing reagent strips for > 100 strips/30 days but ≤ 200 strips/30 days will also usually process at the pharmacy without a PA request if the member has a history of a paid MassHealth pharmacy claim for injectable insulin or a prenatal vitamin within the last 90 days in addition to a history of MassHealth medical claims for visual impairment. 

 

Omnipod, Omnipod Dash, V-Go

  • Documentation of all of the following is required:
    • appropriate diagnosis; and
    • If the request is for V-Go, member is ≥ 18 years of age; and
    • member’s current treatment plan involves testing blood glucose at least four times per day; and
    • member is currently receiving multiple daily insulin injections or an insulin pump; and
    • member’s A1c > 7.0% or does not meet documented target treatment; and
    • one of the following:
      • frequent hypoglycemia; or
      • fluctuations of more than 100 mg/dL in blood glucose before mealtime; or
      • dawn phenomenon with fasting blood sugars frequently exceeding 200 mg/dL; or
      • history of severe glycemic excursions.

 

Zegalogue

  • Documentation of all of the following is required:
    • appropriate diagnosis; and
    • inadequate response, adverse reaction or contraindication to Baqsimi.

 

Note: The decision on whether PA is required is based upon information available in the MassHealth medical claim and pharmacy claim databases. The MassHealth database contains member information exclusive to MassHealth, and no other health plans.


Original Effective Date: 12/2020

Last Revised Date: 09/2021


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Last updated 10/18/21

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