FreeStyle Libre Standard Written Order for Continuous Glucose Monitoring and Supplies Instructions

FreeStyle Libre Standard Written Order for Continuous Glucose Monitoring

and Supplies

Product Information

Specifications

• Product Name: FreeStyle Libre CGM System
• Model: FreeStyle Libre 2
• Model: FreeStyle Libre 3
• Duration of need: Lifetime (99) – unless specified otherwise

Product Usage Instructions

Step 1: Completing the Standard Written Order
Complete all fields on the Standard Written Order form,including patient information, insurance details, and diagnosis.

Step 2: Confirming Coverage Criteria and Medical Necessity
Ensure that the coverage criteria and medical necessity documentation requirements are met. These requirements are essential for insurance coverage.

Step 3: Sending the Order and Medical Records
Send the completed order form along with the patient’s most recent medical records that demonstrate the fulfillment of coverage criteria to a DME supplier that provides the FreeStyle Libre CGM systems.

Step 4: Selecting the Reason for Prescribing CGM
Select the appropriate documented reasons for prescribing CGM to improve the beneficiary’s glycemic control. These reasons include:

• Insulin-treated with 1, 2, or 3+ insulin administrations per day, or insulin pump
• History of problematic hypoglycemia

Step 5: Choosing the Product
Select the desired FreeStyle Libre reader and sensor based on the patient’s needs:

• FreeStyle Libre 2 reader with FreeStyle Libre 2 sensor
• FreeStyle Libre 3 reader with FreeStyle Libre 3 sensor

Ensure that the “DISPENSE AS WRITTEN” option is selected if the beneficiary (or beneficiary’s caregiver) has sufficient training on the proper use of the products prescribed.

Step 6: Physician Attestation and Signature
The physician identified in the Physician Information section must sign and date the order form, certifying that the medical necessity information provided is true, accurate, and complete.

FAQ

What is E-Prescribing?
E-Prescribing refers to a prescriber’s ability to electronically send an accurate, error-free, and understandable prescription directly to a pharmacy or DME supplier from the point-of-care. It improves the quality of patient care.

How can I order the FreeStyle Libre systems through E-Prescribing?
The FreeStyle Libre systems can be ordered through DME suppliers using various E-Prescribing platforms. Some examples include:

• [Insert E-Prescribing Platform 1]
• [Insert E-Prescribing Platform 2]
• [Insert E-Prescribing Platform 3]

Standard Written Order for Continuous Glucose Monitoring and Supplies

Instructions

1. Complete all fields on this Standard Written Order.
2. Confirm coverage criteria1 and medical necessity documentation2 requirements are met.
3. Send this order and the patient’s most recent medical records demonstrating coverage criteria1,2 are met to a DME supplier that provides the FreeStyle Libre CGM systems.

Patient Information

Order Detail

Duration of need: LIFETIME (99) – unless specified otherwise:

FreeStyle Libre 2 reader with FreeStyle Libre 2 sensor| FreeStyle Libre 3 reader with FreeStyle Libre 3 sensor
---|---
• Use FreeStyle Libre 2 reader with FreeStyle Libre 2 sensor per manufacturer guidelines, in accordance with FDA indications for use

•  Change FreeStyle Libre 2 sensor every 14 days

•  Dispense six sensors/ 84 days, or seven sensors/ 98 days

| • Use FreeStyle Libre 3 reader with FreeStyle Libre 3 sensor per manufacturer guidelines, in accordance with FDA indications for use

•  Change FreeStyle Libre 3 sensor every 14 days

•  Dispense six sensors/ 84 days, or seven sensors/ 98 days

DISPENSE AS WRITTEN

The beneficiary (or beneficiary’s caregiver) has sufficient training on the proper use of the products prescribed on this order I certify that I am the physician identified in the “Physician Information” section below and hereby attest that the medical necessity information is true, accurate, and complete to the best of my knowledge. I understand that any falsification, omission, or concealment of material fact may subject me to administrative, civil, or criminal liability.

Physician Information

Medicare coverage is available for the FreeStyle Libre systems if their respective readers are used to review glucose data on some days every month. Medicare and other third party payor criteria apply. Abbott provides this information as a courtesy, it is subject to change and interpretation. The customer is ultimately responsible for determining the appropriate codes, coverage, and payment policies for individual patients. Abbott does not guarantee third party coverage or payment for our products or reimburse customers for claims that are denied by third party payors.

Check ICD-10 code list in the LCD-related Policy Article for applicable diagnoses. †See the Policy Specific Documentation Requirements section of the LCD-related Policy Article.

1. Local Coverage Determination, Glucose Monitors (L33822). https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?LCDId=33822
2. Glucose Monitor,Policy Article (A52464). https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleId=52464.
   See page 2 for Important Safety Information.

E-Prescribing

E-Prescribing is a prescriber’s ability to electronically send an accurate, error-free and understandable prescription directly to a pharmacy, or DME supplier, from the point-of-care and is an important element in improving the quality of patient care1.

The FreeStyle Libre systems are available to order through DME suppliers using a variety of E-Prescribing platforms. Some examples are:

The FreeStyle Libre systems are available to order through DME suppliers using a variety of E-Prescribing platforms.

Some examples are:

This listing of electronic prescribing platforms are in reverse alphabetical order and ADC has no preference on the E-Prescribing platform selected from the list.
The FreeStyle Libre systems may be available through other E-Prescribing platforms not listed here.

FreeStyle Libre Systems DME Suppliers

760-496-0234
Better Living Now/ Rotech Company| 800-854-5729| 877-262-2179
Bridgewater Health Supplies| 800-974-2055| 877-297-5127
Byram Healthcare/Apria| 800-775-4372| 866-387-1127
CCS Medical| 800-599-7521| 800-557-8256
Diabetes Management & Supplies/ AdaptHealth| 888-738-7929| 504-407-2083
Edgepark Medical Supplies| 844-619-4650| 866-510-6583
Edwards Health Care Services| 800-951-1725| 502-657-0237
J&B Medical Supply| 800-737-0045| 800-737-0012
Mini Pharmacy| 888-545-6464| 800-280-2939
Quest Health Solutions| 877-888-7050| 866-422-5283
Solara Medical Supplies/AdaptHealth| 844-381-8032| 800-999-7021
Total Medical Supply| 877-670-1120| 877-670-1121
United States Medical Supply| 877-270-6508| 866-347-8544
US HealthLink| 855-421-2732| 407-440-8122

Last Updated 10/23.
Providers listed above include all DME suppliers who have contracted with ADC to acquire FreeStyle Libre family of products directly as of the “Last Updated” date.
FreeStyle Libre family of products may be available through other suppliers not listed who acquire these products indirectly.
This listing of participating suppliers are in alphabetical order and ADC has no preference on the supplier selected from the list.

Medicare E-Prescribing https://www.cms.gov/medicare/e-health/eprescribing.

Important Safety Information
Failure to use FreeStyle Libre 2 or FreeStyle Libre 3 systems as instructed in labeling may result in missing a severe low or high glucose event and/or making a treatment decision, resulting in injury. If glucose alarms and readings do not match symptoms or expectations, use a fingerstick value from a blood glucose meter for treatment decisions. Seek medical attention when appropriate or contact Abbott at 855-632-8658 or https://www.FreeStyle.abbott/us-en/safety-information.html for safety info.
The sensor housing, FreeStyle, Libre, and related brand marks are marks of Abbott. Other trademarks are the property of their respective owners.
© 2023 Abbott. ADC-54601 v5.0

References

• DMEscripts | ePrescribing for DME - DMEscripts
• Parachute Health - Order Medical Equipment & Supplies
• Article - Glucose Monitor - Policy Article (A52464)
• LCD - Glucose Monitors (L33822)
• E-Prescribing | CMS
• Safety Information | The FreeStyle Libre System

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