Blue Cross Blue Shield of Vermont and The Vermont Health Plan
Blood Glucose Meters and Strips
Step Therapy Guidelines
Fax # (888)–255-1006
Date of Request __________________
Patient Name: ____________________
BCBSVT/TVHP Member ID#:______________ Date of birth: ___________________
Provider Name: ________________________
Provider Phone number:____________
Provider Fax number: ___________________
PCP Name: ______________________
Indicate which strip is being requested:
Roche Accu-chek®
(Aviva Plus, Smartview, Compact)
Bayer
(Breeze 2, Contour, Contour TS)
Arkray
(Assure® Platinum, Assure® Pris, Glucocard®
Expression, Glucocard® Vital, Glucocard® 01,
Glucocard® Shine)
Prodigy®
Truetrack®
Fora® care
(MD, Test N’ Go, Test N’, V10a, V12, V30a,
G30)
OTHER:
______________________
Indicate which Meter is being requested:
Roche Accu-chek®
(Aviva Expert, Aviva Plus, Aviva Connect,
Compact plus, Nano)
Bayer®
(Contour, Contour TS, Breeze 2, Contour
USB)
Arkray
(Assure® Platinum, Assure® Prism Plus,
Glucocard® Expression, Glucocard® Vital,
Glucocard® 01, Glucocard® Shine)
Prodigy
(Autocode®, Pocket®, and Voice®)
Truetrack®
Fora®
(MD, Test N’ Go, Test N’ Go Voice, Premium
V10a, Premium V12, Fora® V30a, Fora®
G30)
OTHER:
______________________
INDICATIONS FOR USE
BCBSVT/TVHP Blood Glucose Meters and Strips Form
Created: 11-2009, rev 04-10, rev 05-16, 1/17
YES
NO
Patient has had a 30 day trial and failure of both preferred brands (Abbott Brand and
J&J’s Lifescan Brand) processed by a prescription. Abbott brand includes Freestyle
product line (Lite, InsuLinx, and Freedom lite) and the Precision product line (Xtra).
Lifescan brand includes OneTouch product line (Ping, Ultra 2, Ultramini, Verio, Verio
Sync, VerioIQ, Verio Flex, Ultra Blue).
If No: Please explain why no trial has taken place.
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
______________________________________________________________________
Does this patient use Medtronics MiniMed® insulin pump system?
PRESCRIBER SIGNATURE__________________________________ DATE_____________
By signing above, the prescriber confirms all information provided is accurate and verifiable via member
records.
BCBSVT/TVHP Blood Glucose Meters and Strips Form
Created: 11-2009, rev 04-10, rev 05-16, 1/17