36:00 Diagnostic Agents

36:00.00 DIAGNOSTIC AGENTS (DX)

COAGULATION MONITORS

Limited use benefit (prior approval required).

For monitoring the international normalized ratio (INR) in patients who require long-term oral anticoagulation.

  • client has difficulty accessing laboratory-based INR testing.

Coverage is limited to 1 meter every 2 years.

Table: COAGULATION MONITORS
Drug strength and dosage form DIN Brand name Manufacturer code
Device 97499983 COAGUCHEK INRANGE METER ROD
Device 97499986 COAGUCHEK XS KIT ROD

COAGULATION TEST

Limited use benefit (prior approval required).

For monitoring the international normalized ratio (INR) in patients who require long-term oral anticoagulation.

  • client has difficulty accessing laboratory-based INR testing.
Table: COAGULATION TEST
Drug strength and dosage form DIN Brand name Manufacturer code
Strip 97499988 COAGUCHEK XS PT STRIPS 24 ROD
Strip 97499987 COAGUCHEK XS PT STRIPS 48 ROD
Strip 97499989 COAGUCHEK XS PT STRIPS 6 ROD

LANCET

Limited use benefit (prior approval not required).

The number of lancets that will be covered by the NIHB Program will depend on the client's medical treatment:

  • clients managing diabetes with insulin will be allowed 800 lancets per 100 days.
  • clients managing diabetes with high risk of causing hypoglycemia will be allowed 400 lancets per 365 days.
  • clients managing diabetes medication with low risk of causing hypoglycemia will be allowed 200 lancets per 365 days.
  • clients managing diabetes through diet/lifestyle therapy only (no insulin or anti-diabetes medications) will be allowed 200 lancets per 365 days.

Please note that the test strip limit is 800/100 days. Due to lancet pack sizes, 800 per 100 days will be reimbursed.

Table: LANCET
Drug strength and dosage form DIN Brand name Manufacturer code
Lancet 97499991 COAGUCHEK LANCETS ROD

36:26.00 DX - DIABETES MELLITUS

GLUCOSE OXIDASE, PEROXIDASE

Limited use benefit (prior approval not required).

The number of test strips that will be covered by the NIHB Program will depend on the client's medical treatment:

  • clients managing diabetes with insulin will be allowed 800 test strips per 100 days. A client can test up to eight times per day.
  • clients managing diabetes with diabetes medication with a high risk of causing low blood sugar will be allowed 400 test strips per 365 days. A client can test once daily.
  • clients managing diabetes with diabetes medication with a low risk of causing low blood sugar will be allowed 200 test strips per 365 days. A client can test three to four times per week.
  • clients managing diabetes with diet/lifestyle therapy only (no insulin or diabetes medications) will be allowed 200 test strips per 365 days. A client can test three to four times per week.
  • non-diabetic clients with rare conditions leading to symptomatic hypo or hyperglycemia will be allowed 800 test strips per 100 days.
Table: GLUCOSE OXIDASE, PEROXIDASE
Drug strength and dosage form DIN Brand name Manufacturer code
ACCU-CHEK ADVANTAGE Strip 09853626 ACCU-CHEK ADVANTAGE ROD
ACCU-CHEK ADVANTAGE Strip 97799824 ACCU-CHEK ADVANTAGE ROD
ACCU-CHEK AVIVA Strip 09857178 ACCU-CHEK AVIVA ROD
ACCU-CHEK AVIVA Strip 97799814 ACCU-CHEK AVIVA ROD
ACCU-CHEK COMPACT Strip 09854282 ACCU-CHEK COMPACT ROD
ACCU-CHEK COMPACT Strip 97799962 ACCU-CHEK COMPACT ROD
ACCU-CHEK MOBILE Strip 09857452 ACCU-CHEK MOBILE BG ROD
ACCU-CHEK MOBILE Strip 97799497 ACCU-CHEK MOBILE CASSETT ROD
ACCUTREND Strip 09853162 ACCUTREND ROD
ACCUTREND Strip 97799959 ACCUTREND ROD
ASCENSIA BREEZE 2 Strip 97799748 ASCENSIA BREEZE 2 BAY
ASCENSIA BREEZE 2 Strip 09857293 BREEZE 2 BG (ON) BAY
ASCENSIA CONTOUR Strip 97799702 ASCENCIA CONTOUR BAY
ASCENSIA CONTOUR Strip 09857127 CONTOUR BG (ON) BAY
BG STAR Strip 97799465 BG STAR SAC
CONTOUR NEXT Strip 97799459 CONTOUR NEXT BAY
CONTOUR NEXT Strip 09857453 CONTOUR NEXT (ON) BAY
EZ HEALTH Strip 09857357 EZ HEALTH ORACLE TRE
EZ HEALTH Strip 97799564 EZ HEALTH ORACLE TRE
FREESTYLE LITE Strip 97799597 FREESTYLE LITE ABB
FREESTYLE LITE Strip 09857297 FREESTYLE LITE (ON) ABB
FREESTYLE PRECISION Strip 97799346 FREESTYLE PRECISION ABB
FREESTYLE PRECISION Strip 09857502 FREESTYLE PRECISION (ON) ABB
FREESTYLE Strip 97799829 FREESTYLE ABB
FREESTYLE Strip 09857141 FREESTYLE (ON) ABB
GE200 Strip 97799373 GE200 AUC
GE200 Strip 09857525 GE200 (ON) AUC
ITEST Strip 09857348 ITEST AUC
ITEST Strip 97799692 ITEST AUC
MEDI+SURE Strip 97799403 MEDI+SURE MEC
MEDI+SURE Strip 09857432 MEDI+SURE (ON) MEC
NOVA MAX Strip 09857313 NOVA MAX NCA
ONE TOUCH ULTRA Strip 09854290 ONE TOUCH ULTRA JAJ
ONE TOUCH ULTRA Strip 97799985 ONE TOUCH ULTRA JAJ
ONE TOUCH VERIO Strip 97799475 ONETOUCH VERIO JAJ
ONE TOUCH VERIO Strip 09857392 ONETOUCH VERIO (ON) JAJ
PRECISION XTRA Strip 09854070 PRECISION XTRA ABB
PRECISION XTRA Strip 97799840 PRECISION XTRA AUC
SIDEKICK Strip 97799601 SIDEKICK HOD
SPIRIT Strip 97799291 FIRST CANHEALTH SPIRIT ARA
SPIRIT Strip 09857547 SPIRIT TEST STRIP (ON) ARA
Strip 09857563 ACCU-CHEK GUIDE (ON) ROD
Strip 97799177 ACCU-CHEK GUIDE (SK) ROD
SURE STEP Strip 97799355 SURE STEP SKY
SURETEST Strip 09857522 SURETEST (ON) SKY
TRUETEST Strip 97799532 TRUETEST HOD
TRUETRACK Strip 09857283 TRUE TRACK AUC
TRUETRACK Strip 97799602 TRUE TRACK HOD

36:60.00 DX - THYROID FUNCTION

THYROTROPIN ALFA

Table: THYROTROPIN ALFA
Drug strength and dosage form DIN Brand name Manufacturer code
0.9MG/ML Powder For Solution 02246016 THYROGEN GEE

36:88.00 DX - URINE AND FECES CONTENTS

URINE TEST STRIP

Table: URINE TEST STRIP
Drug strength and dosage form DIN Brand name Manufacturer code
Strip 97799914 DIASTIX BAY
Strip 97799913 KETOSTIX BAY

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