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New Reasonable & Customary Limits as of January 1, 2015

Diabetes Test Strips

Currently, Pacific Blue Cross limits members to a 100-day supply of blood glucose test strips. Within that supply, members can order an unlimited number of test strips.

On January 1, 2015, Pacific Blue Cross will introduce a Reasonable and Customary Limit of 3,000 test strips per member per calendar year. Members who can prove medical necessity will be granted a larger supply.

What does this mean?

Most plan members that use test strips are well within the limit and won’t be affected.

Members who are newly-diagnosed with diabetes should talk to a pharmacist, doctor or diabetes educator for advice on blood glucose monitoring. Those who take insulin should continue to follow guidelines for routine testing.

Members are encouraged to visit to learn more about blood glucose self-monitoring and diabetes management resources.

Markup limits on high-cost drugs

Pacific Blue Cross is applying Reasonable and Customary Limits to certain high-cost specialty drugs where alternative government and/or patient assistance programs exist.

What does this mean?

Plan members will not be asked to pay out of pocket for these drugs. Costs will be offset by applicable assistance programs.
For example, if a pharmacy charges more than the Reasonable and Customary Limit for one of these drugs, it can either absorb the difference or obtain funding from the applicable assistance program. Members prescribed high-cost specialty drugs can also ask their physicians about supplemental coverage options.

Pacific Blue Cross customer service representatives are equipped with information about high-cost drug coverage to help members understand their options.

Blue Shield

Blue Shield is a registered trade-mark of Blue Cross Blue Shield Association