Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that Medicare may cover a drug or biological if it is safe and effective and otherwise reasonable 
and necessary. You can find this rule in the Medicare Benefit Policy Manual, Chapter 15, Section 50.4.1. 
  
Medicare rules also allow the plan to use step therapy. This is the process of beginning drug therapy for a 
medical condition with "preferred" (or more cost-effective) on-formulary drug alternative(s) and progressing to 
other drug therapies only as necessary. A plan must grant an exception to its step therapy rules if it determines 
that the requested drug is medically necessary, consistent with the prescriber's statement. The statement must 
show that the step therapy drugs: have been ineffective in treating the enrollee; or are likely to be ineffective or 
adversely affect the drug's effectiveness or patient compliance; or are likely to cause an adverse reaction or 
other harm to the enrollee.  
 
Medicare Advantage plans should ensure that new step therapy requirements do not disrupt ongoing Part B 
drug therapies for enrollees. Step therapy may only be applied to new prescriptions or administrations of Part B 
drugs for enrollees that are not actively receiving the affected medication. You can find this information at 42 
CFR Section 423.578(b)(5)(ii). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. This plan 
covers only OneTouch (made by LifeScan, Inc.) and ACCU-CHECK (made by Roche Diagnostics) blood 
glucose test strips and glucometers. We will not cover other brands unless your provider tells us it is medically 
necessary. Blood glucose test strips and glucometers MUST be purchased at a network retail or our mail-order 
pharmacy to be covered. If you purchase these supplies through a Durable Medical Equipment (DME) provider 
these items will NOT be covered. Lancets are limited to the following manufacturers:  LifeScan / Delica, 
Roche, Kroger and its affiliates which include Fred Meyer, King Soopers, City Market, Fry's Food Stores, 
Smith's Food and Drug Centers, Dillon Companies, Ralphs, Quality Food Centers, Baker, Scott's, Owen, 
Payless, Gerbes, Jay-C, Prodigy, and Good Neighbor. If you are using a brand of diabetic test strips or lancets 
that is not covered by our plan, we will continue to cover it for up to two fills during the first 90 days after 
joining our plan. The meter will only be filled once during the transition period. This 90-day transitional 
coverage is limited to once per lifetime. During this time, talk with your doctor to decide what brand is 
medically best for you. Your provider must get an approval from the plan before we'll pay for test strips or 
lancets greater than the amount listed above or are not from the approved manufacturers. You can find this 
information in Chapter 4 on page 53 of the plan's 2020 Evidence of Coverage.