Download Diabetes Supply Coverage

ADMINISTRATIVE POLICY
DIABETES SUPPLY COVERAGE
Policy Number: DIABETIC 009.15 T2
Effective Date: December 1, 2014
Table of Contents
Page
CONDITIONS OF COVERAGE...................................
BENEFIT CONSIDERATIONS....................................
COVERAGE RATIONALE...........................................
DESCRIPTION OF SERVICES………………………
APPLICABLE CODES.................................................
REFERENCES............................................................
POLICY HISTORY/REVISION INFORMATION...........
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Related Policies:
 Continuous Glucose
Monitoring and
Insulin Delivery
Device
 Diabetes Supply
Coverage for New
Jersey Small and
Individual Plans
The services described in Oxford policies are subject to the terms, conditions and limitations of the
Member's contract or certificate. Unless otherwise stated, Oxford policies do not apply to Medicare
Advantage enrollees. Oxford reserves the right, in its sole discretion, to modify policies as necessary without
prior written notice unless otherwise required by Oxford's administrative procedures or applicable state law.
The term Oxford includes Oxford Health Plans, LLC and all of its subsidiaries as appropriate for these
policies.
Certain policies may not be applicable to Self-Funded Members and certain insured products. Refer to the
Member's plan of benefits or Certificate of Coverage to determine whether coverage is provided or if there
are any exclusions or benefit limitations applicable to any of these policies. If there is a difference between
any policy and the Member’s plan of benefits or Certificate of Coverage, the plan of benefits or Certificate of
Coverage will govern.
CONDITIONS OF COVERAGE
Applicable Lines of Business/Products
This policy applies to Oxford Commercial plan
and Oxford USA membership
Note: For New Jersey Small and Individual
Plans, refer to Diabetes Supply Coverage for
New Jersey Small and Individual Plans.
General benefits package
1
Pharmacy
No
Benefit Type
Referral Required
(Does not apply to non-gatekeeper products)
2, 3
Authorization Required
No
(Precertification always required for inpatient admission)
Precertification with Medical Director
Review Required
Applicable Site(s) of Service
No
All
(If site of service is not listed, Medical Director review is
required)
Special Considerations
Special Considerations
(continued)
1
A prescription is required when accessing
coverage through a participating retail pharmacy
or through Oxford's mail order pharmacy. A
prescription is not required in order to receive
reimbursement through Oxford if a Member
pays out-of-pocket.
2
Precertification required for Insulin Pumps.
Diabetes Supply Coverage: Administrative Policy (Effective 12/01/2014)
©1996-2014, Oxford Health Plans, LLC
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3
Precertification is required for A9275 when it is
billed as part of a continuous glucose monitoring
and insulin delivery device.
BENEFIT CONSIDERATIONS
Please refer to the Member's certificate of coverage, summary of benefits, and/or health benefits
plan documentation for specific details regarding benefit coverage, exclusions, limitations and/or
maximums.
Unless otherwise noted in this policy or the Member's benefit script, diabetes supplies will be
applied towards the Member's medical benefit subject to individual office co-payment and/or coinsurance.
New Jersey Large Group plans:
Diabetic drugs and medications (including insulin, oral agents such as glucose tablets and gels,
Glucagon for use with injections to increase blood glucose concentration and oral anti-diabetic
agents used to reduce blood sugar levels) are subject to the Copayment (or Deductible and
Coinsurance) listed on the Member's Summary of benefits.


If the Group has purchased the supplemental pharmacy benefit, the Copayments listed
under Supplemental Outpatient Prescription Drug Coverage will apply for diabetic drugs
and medications.
If the Group has not purchased the Supplemental Outpatient Prescription Drug benefit,
the office visit Copayment (or Deductible and Coinsurance) will apply.
The Copayment or Coinsurance is applicable to each 30-day supply.
COVERAGE RATIONALE
Oxford will cover medically-necessary equipment, drugs and supplies for the treatment of all
Members with insulin dependent, insulin requiring, non-insulin dependent (Type 1 and 2) and
gestational diabetes for all commercial plans as prescribed by a health care professional legally
authorized to prescribe such items. Oxford will cover supplies, drugs, and equipment for diabetes
as outlined in the following tables regardless of whether the Member has a DME rider or medical
supply rider.
Access to Diabetes Supply Coverage:
Members may have several options in accessing diabetes supplies, depending on the Member's
line of business and benefits:


Members with a prescription drug benefit may be able to obtain diabetes supplies through
a participating retail network pharmacy. A prescription is required when accessing
coverage through a network retail pharmacy.
Members with mail order coverage as part of their pharmacy benefit can obtain certain
diabetes supplies either through a participating retail network pharmacy or Oxford's mail
order vendor. A prescription is required when accessing coverage through Oxford's mail
order vendor.
All Members may pay out-of-pocket for their supplies and submit a receipt, noting the
member's name, Oxford ID, total cost, the type of supply and quantity purchased, to Oxford
for reimbursement. A prescription is not required in order to receive reimbursement if a
Member pays out-of-pocket.
Oxford will cover diabetes supplies per the quantity limitations noted in the Applicable Codes
section below.
DESCRIPTION OF SERVICES
Diabetes Supply Coverage: Administrative Policy (Effective 12/01/2014)
©1996-2014, Oxford Health Plans, LLC
2
Supplies for Members with Diabetes such as insulin, test strips, lancets, blood glucose meters,
syringes, insulin pumps, tubing, etc. are covered per state regulation in CT, NJ, NY and PA.
APPLICABLE CODES
®
The Current Procedural Terminology (CPT ) codes and Healthcare Common Procedure Coding
System (HCPCS) codes listed in this policy are for reference purposes only. Listing of a service
code in this policy does not imply that the service described by this code is a covered or noncovered health service. Coverage is determined by the enrollee specific benefit document and
applicable laws that may require coverage for a specific service. The inclusion of a code does not
imply any right to reimbursement or guarantee claims payment. Other policies and coverage
determination guidelines may apply. This list of codes may not be all inclusive.
Needle-free injection device, each
(e.g. Inject-Ease, Medijector, Injex)
Replacement battery, alkaline (other
than J cell), for use with medically
necessary home blood glucose
2
monitor owned by patient, each
Replacement battery, alkaline, J cell,
for use with medically necessary
home blood glucose monitor owned
2
by patient, each
Replacement battery, lithium, for use
with medically necessary home
blood glucose monitor owned by
2
patient, each
Replacement battery, silver oxide, for
use with medically necessary home
blood glucose monitor owned by
2
patient, each
Alcohol, per pint
Alcohol wipes
Urine test or reagent strips or tablets
(100 tablets or strips)
Blood Glucose test or reagent strips
for home glucose monitor
A4210
Allowable Qty.
per 30 day supply
Per prescription
limitation.
2 per year
A4233
-
Yes-lowest office medical
A4234
-
Yes-lowest office medical
A4235
-
Yes-lowest office medical
A4236
-
Yes-lowest office medical
A4244
A4245
A4250
4 pints
8 boxes
2 Boxes
Yes-lowest office medical
Yes-lowest office medical
Yes-lowest office medical
A4253
Yes-lowest office
1, 3
medical
Normal, low and high calibrator
solution/chips
Spring powered device for lancet
Lancets, per box of 100
Home glucose disposable monitor,
includes test strips
Blood Glucose Monitor
A4256
Refer to QD
Supply Limits and
QLL Supply Limits
-
Yes-lowest office medical
Yes-lowest office medical
Yes-lowest office medical
Blood Glucose Monitor with special
features (i.e., voice synthesizers)
2
Insulin Pump
Replacement battery for external
infusion pump owned by patient,
2
silver oxide, 1.5 Volt, each
E2100E2101
E0784
K0601
2 per year
4 boxes
1 per year (from
date of purchase)
1 per year (from
date of purchase)
1 per year (from
date of purchase)
Per Authorization
-
Item
Syringes, sterile, with needle
HCPCS
Code
A4206
A4258
A4259
4
A9275
E0607
Diabetes Supply Coverage: Administrative Policy (Effective 12/01/2014)
©1996-2014, Oxford Health Plans, LLC
Cost Share applied?
Yes-lowest office medical
Yes-lowest office medical
Yes-lowest office medical
Yes-lowest office medical
Yes-lowest office medical
Yes-lowest office medical
Yes-lowest office medical
3
Replacement battery for external
infusion pump owned by patient,
2
silver oxide, 3 Volt, each
Replacement battery for external
infusion pump owned by patient,
2
alkaline, 1.5 Volt, each
Replacement battery for external
infusion pump owned by patient,
2
lithium, 3.6 Volt, each
Replacement battery for external
infusion pump owned by patient,
2
lithium, 4.5 Volt, each
Insulin set for external insulin pump ,
2
non-needle cannula type
Infusion set for external insulin
2
pump, needle type
Syringe with needle for external
2
2
insulin pump ,sterile, 3cc
Transparent film, 16 sq. in. or less,
2
each dressing, 3cc
Insulin
K0602
-
Yes-lowest office medical
K0603
-
Yes-lowest office medical
K0604
-
Yes-lowest office medical
K0605
-
Yes-lowest office medical
A4230
20 sets
3
Yes-lowest office medical
A4231
20 sets
3
Yes-lowest office medical
A4232
20 syringes
A6257
1 box
Yes-lowest office medical
Per prescription
Yes-lowest office
1
medical
Insulin Pen Needles
Prescription oral anti-diabetes agents
J1815
and
J1817
J3490
Yes-lowest office medical
Yes-lowest office
1
medical
Glucagon
J1610
Insulin Pen
Disposable pre-filled insulin pens
-
3 boxes
Refer to QD
Supply Limits and
QLL Supply Limits
Refer to QD
Supply Limits and
QLL Supply Limits
2 pens
4 boxes
Cartridges for Pen Injector
-
Per prescription
Glucose Tabs
-
30 tablets
3
Yes-lowest office medical
Yes-lowest office
1
medical
Yes-lowest office medical
Yes-lowest office
1
medical
Yes-lowest office
1
medical
Yes-lowest office medical
1
If a pharmacy benefit is present, Members of self-funded groups, as well as Members of groups
with in-network medical office coinsurance/deductibles, will be charged applicable pharmacy
copayment(s)for these items if they are transmitted through a participating retail pharmacy or
through Oxford's pharmacy mail order vendor.
2
These items are not available for coverage through participating retail pharmacies or through
Oxford's mail order pharmacy vendor, even if the Member has the appropriate pharmacy benefit.
They must be purchased out of pocket and submitted to Oxford for reimbursement.
3
If a Member's needs exceed the maximum quantity the vendor will request a written verification
from the endocrinologist, stating the reason. This written verification needs to be updated
annually.
4
When A9275 it is billed as part of a Continuous Glucose Monitoring and Insulin Delivery Device,
refer to Continuous Glucose Monitoring and Insulin Delivery for Managing Diabetes.
REFERENCES
1. Oxford Certificate of Coverage and Member Handbook
2. State Regulations:
State
CT
Regulation
38a-492d; 38a-518d
Diabetes Supply Coverage: Administrative Policy (Effective 12/01/2014)
©1996-2014, Oxford Health Plans, LLC
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NJ
NY
17B: 26-2.11; 17B: 27-46.1M; 26:2J-4.11
NY Ins. Law s 3221; NY Ins. Law s 3216
3. American Medical Association. Healthcare common Procedure Coding System. Medicare's
National Level II Codes HCPCS.
POLICY HISTORY/REVISION INFORMATION
Date

08/01/2016

12/01/2014

Action/Description
Replaced reference link to related policy Prescription Drug
Quantity Duration (QD) and Quantity Level Limitations (QLL) with
QD Supply Limits and QLL Supply Limits.
Changed policy type classification from “Clinical” to
“Administrative” (no change in content/guidelines)
Archived previous policy version DIABETIC 009.14 T2
Diabetes Supply Coverage: Administrative Policy (Effective 12/01/2014)
©1996-2014, Oxford Health Plans, LLC
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