Download Self-Monitoring Blood Glucose System Test Strips

US Family Health Plan Pharmacy Program Medical Necessity Form for
Self-Monitoring Blood Glucose System (SMBGS) Glucose Test Strips
This form applies to the US Family Health Plan Mail Order Pharmacy and the US Family Health Plan Retail Pharmacy programs. The form must be completed and signed by
the prescriber.
 FreeStyle Lite and Precision Xtra are the formulary test strips on the DoD Uniform Formulary. Other test strips are non-formulary, but available to
most beneficiaries at the non-formulary cost share.
 You do NOT need to complete this form in order for non-Active duty beneficiaries (spouses, dependents, and retirees) to obtain
non-formulary medications at the non-formulary cost share. The purpose of this form is to provide information that will be used to determine if the use of
a non-formulary medication is medically necessary. If a non-formulary medication is determined to be medically necessary, non-Active duty
beneficiaries may obtain it at the formulary cost share.
MAIL ORDER
and
RETAIL
 Active duty service members may not fill prescriptions for a non-formulary medication unless it is determined to be medically necessary. There is no
cost share for active duty service members at any DoD pharmacy point of service.
Step
1
Step
2
• The provider may call: 1-877-880-7007 or the completed form may be faxed to:
1-617-562-5296
• The patient may attach the completed form to the prescription and mail it to:
ATTN: Phamacy, 77 Warren Street, Brighton, MA 02135
Please complete patient and physician information (please print):
Patient Name:
Address:
Physician Name:
Address:
Sponsor ID #
Date of Birth:
Phone #:
Secure Fax #:
Please document:
Brand / name of requested test strip: ___________________________________________
Brand / name of meter: ___________________________________________
Brand / name of insulin pump (if applicable): ___________________________________________
Step Please explain why the patient cannot use a formulary test strip. Circle a reason code if it applies. You
3
MUST provide a supporting patient-specific Clinical Explanation why use of a formulary test strip would
be unacceptable.
Formulary test strips
FreeStyle Lite
Precision Xtra
Reason
Clinical Explanation
1 2 3
Clinical exception can be considered for:
1.
2.
3.
Step
4
Patient is blind or severely visually impaired and requires a test strip used in a talking meter.
Patient uses an insulin pump and requires a specific test strip used in a meter that communicates wirelessly with the
insulin pump.
The patient has a documented physical or mental health disability that requires use of a special strip or meter.
I certify the above is true to the best of my knowledge. Please sign and date:
Prescriber Signature
Date
[15 January 2016 ]