Continuous Glucose Monitors Regular Durable Medical Supplies Limits

Date: September 24, 2021 Attention: Endocrinologists, PCPs and DME Providers Subject: Continuous Glucose Monitors Regular Durable Medical Supplies Limits Effective Date: August 1, 2021Providers should monitor the Texas Children’s Health Plan (TCHP) Provider Portal regularly for alerts and updates associated to the COVID-19 event.  TCHP reserves the right to update and/or change this information without prior notice due to the evolving nature of the COVID-19 event. Call to action: Texas Children’s Health Plan (TCHP) would like to inform providers of new limits for diabetic supplies processed through the medical benefit for members utilizing continuous glucose monitors [CGM] (HCPCS Code K0553). Diabetic supplies include lancets, test strips, among others. How this impacts providers: Members with CGMs generally do not require glucose monitoring using traditional supplies. In the event members with CGMs require additional or backup diabetic supplies, TCHP prefers members and providers obtain supplies  through the medical benefit. For emergent situations, members may obtain supplies through retail pharmacy benefit. Prior Authorization is not required for requests made within the new limits. Over the new limit, requests will require prior authorization for dates of service on or after August 1, 2021.

HCPCS Code	Description	Old Limit	New Limit
A4233	Replacement battery, alkaline (other than j cell), for use with medically necessary home blood glucose monitor	1 per 6 months	1 per 12 months
A4236	Replacement battery, silver oxide, for use with medically necessary home blood glucose monitor	1 per 6 months	1 per 12 months
A4250	Urine test or reagent strips or tablets (100 tablets or strips)	1 per 6 months	1 per 12 months
A4253	Blood glucose test or reagent strips for home blood glucose monitor	50 strips – 2 per month	2 boxes per year  - 100 strips per year
A4256	Normal, low and high calibrator solution / chips or just “Calibrator solution/chips	Twice within 2 years	No change
A4258	Spring-powered device for lancet, each or just “Lancet device each”	Twice within 2 years	No change
A4259	Lancets, per box of 100 or just “Lancets per box”	One box per month	1 box per year, 100 Lancets per year
A9275	Home glucose disposable monitor	2  within 1 month	1 box per year

Next steps for providers: Providers should share this communication with their staff. Providers should submit DME supply requests for members with CGM through the medical benefit, and inform  members that they can obtain supplies through retail pharmacy benefit for emergent situations. If you have any questions, please email Provider Network Management at: providerrelations@texaschildrens.org.For access to all provider alerts,log into: www.thecheckup.org or www.texaschildrenshealthplan.org/for-providers.