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Includes sections to select preferred diabetic meters, test strips/diabetic supplies, and continuous glucose monitors (CGM), with options for preferred vs non-preferred products. Documents clinical criteria such as insulin pump use, meter type, vision impairment requirements, diagnosis code, HbA1c, hypoglycemia history, and renewal criteria with CGM treatment metrics. Requires prescriber signature, date, fax/phone submission, and includes PHI confidentiality notice.",{"@graph":63,"@context":118},[64,80,101],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/diabetic-supplies-prior-authorization-form-read-online-free/287446/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/diabetic-supplies-prior-authorization-form-read-online-free/287446.png","ImageObject",442,249,{"name":88,"@type":89},"Melati","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-09-26","2026-09-17",true,{"@type":98,"interactionType":99,"userInteractionCount":47},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104,110,114],{"name":105,"@type":106,"acceptedAnswer":107},"What information is required for the member section of this form?","Question",{"text":108,"@type":109},"The form requires member name, insurance ID, date of birth, and address/contact details including city, state, zip, and phone.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"Which CGM options can be selected in the Continuous Glucose Monitors (CGM) section?",{"text":113,"@type":109},"The form lists preferred options such as Dexcom G7 and Dexcom G6, and non-preferred options including Eversense (and Eversense E3), Freestyle Libre 2 and 3, Guardian Connect, Guardian Link and Sensor 3 or Guardian 4, and an Other choice.",{"name":115,"@type":106,"acceptedAnswer":116},"What renewal criteria does the form ask for?",{"text":117,"@type":109},"For renewals, it requests the date of last endocrinology/diabetes management evaluation, updated HbA1c with date taken, and proof of improvement or compliance using measures such as decreased A1c, decreased hypoglycemia, decreased time below range (TBR), increased time in range (TTR), or other details, plus submission of supporting medical documentation.","https://schema.org",{"og:url":78,"og:type":120,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":122,"canonical":78},"index,follow",{"doc_id":124,"site_id":56},287446,1790051556,{"code":4,"msg":5,"data":127},{"doc_id":124,"user_id":128,"nickname":88,"user_avatar":129,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":47,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":73,"language":135,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":136,"faqs":137,"seo_title":138,"seo_description":61,"update_tm":139,"read_time":9},962085570644,"https://ap-avatar.wpscdn.com/davatar_994ba38a5ba835b3df7d355c54d3ed8d","Prior Authorization Form  \nDiabetic Supplies  \nAccess this PA form at: Diabetic Supply PA Form.pdf ([optumrx.com](optumrx.com))  \nIf the following information is not complete, correct, or legible, the PA process can be delayed. Use one form per member please.  \n\n| Member Information (required) |  |  | Prescriber Information (required) |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- |\n| Member Name: |  |  | Provider Name: |  |  |  |\n| Insurance ID\\#: |  |  | NPI\\#: |  | DEA \\#: |  |\n| Date of Birth: |  |  | Specialty: |  |  |  |\n| Street Address: |  |  | Office Phone: |  | Office Fax: |  |\n| City: | State: | Zip: | Office Street Address: |  |  |  |\n| Phone: |  |  | City: | State: |  | Zip: |\n|  |  |  | Is the prescriber a Tenncare provider with a Medicaid ID? ☐ Yes ☐ No\u003Cbr>Is the prescriber a single-patient contract holder for this patient? ☐ Yes ☐ No |  |  |  |\n\n\n| METERS |  |  |  |\n| --- | --- | --- | --- |\n| Johnson and Johnson Products | Bayer Products | Roche Products | Others |\n| ☐ One Touch Ultra Mini | ☐ Breeze – 2 | ☐ Accu – ChekAvia | ☐ AgaMatrix |\n| ☐ One Touch Ultra – 2 | ☐ Contour | ☐ Accu – Chek Compact Plus | ☐ Home Diagnostics |\n| ☐ One Touch UltraSmart | ☐ Didget | ☐ Accu – Chek Advantage | ☐ Other: |\n| ☐ One Touch UltraLink |  |  |  |\n| ☐ One Touch Ping |  |  |  |\n| ☐ Other Johnson & Johnson |  |  |  |\n| TEST STRIPS AND OTHER DIABETIC SUPPLIES |  |  |  |\n| ☐ AgaMatrix Diabetic Supplies |  | ☐ Roche Accu – Chek Aviva Strips |  |\n| ☐ Bayer Contour Strips |  | ☐ Roche Accu – Chek Compact Plus Strips |  |\n| ☐ Bayer Breeze 2 Strips |  | ☐ Roche Accu – Chek Comfort Curve Strips |  |\n| ☐ Home Diagnostics Diabetic Supplies |  | ☐ Roche Accu – Chek Active Strips |  |\n| ☐ Johnson & Johnson One Touch Diabetic Supplies |  | ☐ Other: |  |\n| Continuous Glucose Monitors (CGM) |  |  |  |\n| Preferred |  | Non-preferred |  |\n| ☐ Dexcom G7 |  | ☐ Eversense |  |\n| ☐ Dexcom G6 |  | ☐ Eversense E3 |  |\n|  |  | ☐ Freestyle Libre 2 |  |\n|  |  | ☐ Freestyle Libre 3 |  |\n|  |  | ☐ Guardian Connect |  |\n|  |  | ☐ Guardian Link and Sensor 3 or Guardian 4 (only compatible with Minimed insulin pump) |  |\n|  |  | ☐ Other: |  |\n\nClinical Criteria Documentation  \n1. Is the patient using an Insulin Pump?  \n1a. What type of Insulin Pump is the patient using?  \n1b. What type of meter is the patient using?  \n☐ Yes (Goto 1a)☐ Minimed 630G, 770G, or 780G  \n☐ One Touch Ping by Animas  \n☐ No  \n☐ Other:  \n___________________  \n☐ One Touch UltraLink  \n☐ Contour Link  \n☐ One Touch Ping ☐ Contour NextLink  \n☐ Guardian Link and Sensor 3 or Guardian 4  \n☐Other:    \nThis document and others if attached contain information that is privileged, confidential and/or may contain protected health information (PHI) . The Provider named above is required to safeguard PHI by applicable law. The information in this document is for the sole use of OptumRx. Proper consent to disclose PHI between these parties has been obtained. If you received this document by mistake, please know that sharing, copying, distributing or using information in this document is against the law. If you are not the intended recipient, please notify the sender immediately.  \nOffice use only: DiabeticSupplies_TennCare_ 2023July  \nRevision Date: 7/1/2023  \nPrior Authorization Form Diabetic Supplies  \n1c. Does the patient require a specialized meter for vision impairment? ☐ Yes  \n2. What is the diagnosis code?    \n3. Please provide the patient’s HbA1c level:   Date taken:    \n4. Does the patient require frequent use of inulin (≥ 3 times per day)? ☐ Yes  \n5. Has the patient experienced any of the following:  \n☐Frequent hypoglycemia or nocturnal hypoglycemia episodes with blood glucose \u003C 50 mg/dL ☐History of hypoglycemic unawareness  \n☐Dawn phenomenon with fasting blood sugars frequently exceeding 200mg/dL  \n☐History of emergency room visit or hospitalization related to ketoacidosis or hypoglycemia  \n☐ No  \n☐ No  \nFor Renewals:  \n1. Please provide date patient was last evaluated by endocrinolog","cbCaioa77BakjRrG","https://ap.wps.com/l/cbCaioa77BakjRrG","pdf",118326,"English","# Member Information (required)\n# Prescriber Information (required)\n# Meters\n## Test Strips and Other Diabetic Supplies\n# Continuous Glucose Monitors (CGM)\n# Clinical Criteria Documentation\n## Insulin Pump and Meter Type\n## Diagnosis Code and Lab Values\n## Hypoglycemia and Related History\n# Renewals\n## Endocrinologist Evaluation Date\n## HbA1c and CGM Treatment Improvement","[{\"question\":\"What information is required for the member section of this form?\",\"answer\":\"The form requires member name, insurance ID, date of birth, and address/contact details including city, state, zip, and phone.\"},{\"question\":\"Which CGM options can be selected in the Continuous Glucose Monitors (CGM) section?\",\"answer\":\"The form lists preferred options such as Dexcom G7 and Dexcom G6, and non-preferred options including Eversense (and Eversense E3), Freestyle Libre 2 and 3, Guardian Connect, Guardian Link and Sensor 3 or Guardian 4, and an Other choice.\"},{\"question\":\"What renewal criteria does the form ask for?\",\"answer\":\"For renewals, it requests the date of last endocrinology/diabetes management evaluation, updated HbA1c with date taken, and proof of improvement or compliance using measures such as decreased A1c, decreased hypoglycemia, decreased time below range (TBR), increased time in range (TTR), or other details, plus submission of supporting medical documentation.\"}]","Diabetic Supplies Prior Authorization Form - Read online free | PDF",1789632340]