FreeStyle Libre 3 Plus Sensor

ODB Formulary Therapeutic Classification

• 96:09:00 Flash Glucose Monitoring System

Therapeutic Note

ATC Code

Interchangeable Products

NO  

LU Clinical Criteria

NO  

Requirements

Reimbursement Criteria and Maximum Reimbursed Quantity:

All ODB eligible recipients on insulin therapy for diabetes who have a valid prescription

from a physician or nurse practitioner for CGM sensors and/or a CGM reader/receiver

designated on the Formulary are eligible to receive the prescribed ODB-funded CGM

sensors and/or reader/receiver.

Patients who meet the reimbursement criteria are eligible for a maximum reimbursed

quantity of 31 sensors over the course of a 365-day period.

Please refer to the Ontario Drug Programs Reference Manual for more information

related to CGM systems (e.g., pharmacy billing procedure, HNS response codes and

messages).

EAP Criteria

  NO

Product Monograph

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