Miscellaneous
Miscellaneous Devices, Testing Supplies

Brand/Generic Name Dosage/Strength Status Restrictions Notes Relative Cost
Accu-Chek Aviva
blood sugar diagnostic		 Strip   notreimb.gif (545 bytes)

priorauth.gif (377 bytes)

Not Applicable
Accu-Chek Comfort Curve Test
blood sugar diagnostic		 Strip   notreimb.gif (545 bytes)

priorauth.gif (377 bytes)

Not Applicable
Accu-Chek Compact Plus Care
blood-glucose meter, drum-type		 Kit   notreimb.gif (545 bytes)

priorauth.gif (377 bytes)

Not Applicable
Accu-Chek SmartView
blood sugar diagnostic		 Strip   notreimb.gif (545 bytes)

priorauth.gif (377 bytes)

Not Applicable
Advocate Blood Glucose Monitor
blood-glucose meter		 Misc   notreimb.gif (545 bytes)

priorauth.gif (377 bytes) ql.gif

Not Applicable
Ascensia Breeze 2
blood-glucose meter, disc-type		 Kit   notreimb.gif (545 bytes)

priorauth.gif (377 bytes)

Not Applicable
Ascensia Contour
blood-glucose meter		 Kit   notreimb.gif (545 bytes)

priorauth.gif (377 bytes)

Not Applicable
Ascensia Contour Test
blood sugar diagnostic		 Strip   notreimb.gif (545 bytes)

priorauth.gif (377 bytes)

Not Applicable
Contour Next Strips
blood sugar diagnostic		 Strip   notreimb.gif (545 bytes)

priorauth.gif (377 bytes)

Not Applicable
FastTake Test
blood sugar diagnostic		 Strip   approved.gif (510 bytes)  

NOTES.gif (377 bytes)

$$$
FreeStyle Freedom Lite
blood-glucose meter		 Kit   notreimb.gif (545 bytes)

priorauth.gif (377 bytes)

Not Applicable
Freestyle InsuLinx Test Strips
blood sugar diagnostic		 Strip   notreimb.gif (545 bytes)

priorauth.gif (377 bytes)

Not Applicable
FreeStyle Lite Strips
blood sugar diagnostic		 Strip   notreimb.gif (545 bytes)

priorauth.gif (377 bytes)

Not Applicable
FreeStyle Test
blood sugar diagnostic		 Strip   notreimb.gif (545 bytes)

priorauth.gif (377 bytes)

Not Applicable
Ketone Blood Test generic.gif (400 bytes)
Ketone Blood Test		 Strip   notreimb.gif (545 bytes)  

Not Applicable
Ketone Urine Test generic.gif (400 bytes)
acetone (urine) test		 Strip   nonform.gif (625 bytes)  

Not Applicable
Non-Lifescan Meters
Glucose Blood		 Diagnostic Test   nonform.gif (625 bytes)

Not Applicable
Nova Max Glucose Test
blood sugar diagnostic		 Strip   notreimb.gif (545 bytes)

priorauth.gif (377 bytes)

Not Applicable
One Touch Test
blood sugar diagnostic		 Strip   approved.gif (510 bytes)  

NOTES.gif (377 bytes)

$$$
One Touch Ultra Test
blood sugar diagnostic		 Strip   approved.gif (510 bytes)  

NOTES.gif (377 bytes)

$$$
One Touch Verio
blood sugar diagnostic		 Strip   approved.gif (510 bytes)

st.gif

$$$
One Touch Verio IQ
blood-glucose meter		 Kit   approved.gif (510 bytes)

ql.gif st.gif

NOTES_restrict.gif (377 bytes)

$$$
OneTouch Test
Glucose Blood		 Strip   approved.gif (510 bytes)  

NOTES.gif (377 bytes)

$$$
OneTouch Ultra Blue
Glucose Blood		 Diagnostic Test   approved.gif (510 bytes)  

NOTES.gif (377 bytes)

$$$
Precision Xtra Test
blood sugar diagnostic		 Strip   notreimb.gif (545 bytes)

priorauth.gif (377 bytes)

Not Applicable
Prodigy Autocode Meter
blood-glucose meter		 Kit   notreimb.gif (545 bytes)

priorauth.gif (377 bytes) ql.gif

Not Applicable
Prodigy AutoCode PRO
blood-glucose meter		 Kit   notreimb.gif (545 bytes)

priorauth.gif (377 bytes) ql.gif

Not Applicable
Prodigy Pocket Meter
blood-glucose meter		 Kit   notreimb.gif (545 bytes)

priorauth.gif (377 bytes) ql.gif

Not Applicable
Prodigy Pocket PRO
blood-glucose meter		 Kit   notreimb.gif (545 bytes)

priorauth.gif (377 bytes) ql.gif

Not Applicable
Prodigy Voice PRO
blood-glucose meter		 Kit   notreimb.gif (545 bytes)

priorauth.gif (377 bytes) ql.gif

Not Applicable
SureStep Test
blood sugar diagnostic		 Strip   approved.gif (510 bytes)  

NOTES.gif (377 bytes)

$$$
Truetest Test Strips
blood sugar diagnostic		 Strip   notreimb.gif (545 bytes)

priorauth.gif (377 bytes)

Not Applicable
Truetrack Test
blood sugar diagnostic		 Strip   notreimb.gif (545 bytes)

priorauth.gif (377 bytes)

Not Applicable

Key for Product(s) Listed Above
Formulary Prior Authorization (PA may not be required for some benefit plans) Non-Formulary
(Third tier coverage applies for selected plans)		 Not Reimbursed
Quantity Limit Not available through mail order as 90-day supply* Step Therapy Generic Available. Brand name medication may be covered at a higher member cost or may not be covered for certain plans.
Notes $Relative cost compared to others in category Specialty distribution for selected plans (Fourth or fifth tier coverage applied for selected plans)

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