| Benefit Coverage | Med/Surg Supplies |
| DME | Needle Free Injector Device (Jet sprayers) |
| DME | Infusion set for external insulin pump, non-needle cannula type |
| DME | Infusion set for external insulin pump, needle type |
| DME | Inserts/fittings, shoe, diabetic |
| DME | External ambulatory infusion pump, insulin |
| DME | Orthotics |
| DME | Replacement battery, any type for use with blood glucose monitor |
| DME | Platforms for blood glucose monitor |
| DME or Free Program | Home blood glucose monitor with special features (Accu-Chek Brands) |
| Not Covered | Supplies for self-administration injections |
| Not Covered | Alcohol wipes |
| RX | Insulin Syringe w/Needle, sterile 1cc |
| RX | Urine glucose/latone test or reagent strips, tablets or tape |
| RX | Blood glucose test or reagent strips for home blood glucose monitor |
| RX | Calibration solution (high/low controls) |
| RX | Lancets |
| RX | Insulin pen/pen needles |
| RX | Insulin vials/cartridges |
| RX | Oral Diabetic Drugs |
| RX | Spring-powered device for lancet |
| RX | Lancing Device (Microlet Vaculance) |
| RX | Vaculance |
Please refer to this sheet for coverage of diabetic supplies. The benefit coverage marked RX can be processed through the point of sale system (Member must have a prescription)
Coverage applies to all Blue Cross and First Priority Health Members (including members with no RX coverage).
All coverage on RX supplies are subject to their copay. Members without the RX benefit coverage are subject to an $8.00 copay on all diabetic RX supplies.
All members must use a participating provider pharmacy.
If you have any questions please contact the Pharmacy Management Department at 1-800-722-4062.
No pre-cert is necessary for DME and no PA is required for the above supplies.
Members that do not have a DME rider will be given a $2500.00 Maximum DME Diabetic Supply Rider. One of the main suppliers for insulin pump supplies is Minimed and they are aware of the coverage for Diabetic Supplies and the maximum amount allowed for DME.