Medical Supplies and Durable Medical Equipment

BRAND NAME: Dexcom G4 Plat Ped Receiver

GENERIC NAME: 
blood-glucose meter,continuous No Generic Available
  Status Notes or Restrictions
Anthem Blue Cross (HMO, PPO, EPO) nonform.gif (625 bytes) NOTES_restrict.gif (377 bytes)
Cigna + Oscar notlisted.gif (324 bytes)  
Health Net priorauth.gif (816 bytes) NOTES_restrict.gif (377 bytes)
Kaiser Foundation Health Plan Northern California approved.gif (510 bytes)  
Kaiser Foundation Health Plan Southern California approved.gif (510 bytes)  
Oscar preferred.gif (540 bytes)  
Sharp Health Plan notlisted.gif (324 bytes)  
Sutter Health Plus notlisted.gif (324 bytes)  
UnitedHealthcare notlisted.gif (324 bytes)  
Western Health Advantage notlisted.gif (324 bytes)  


preferred.gif (540 bytes)  Preferred

approved.gif (510 bytes)   Approved

priorauth.gif (816 bytes)  Prior Auth.
nonform.gif (625 bytes)    Non-Formulary notreimb.gif (645 bytes)   Not Reimbursed notlisted.gif (324 bytes)   Not Listed
nonform.gif (625 bytes)    Benefits/Policies generic.gif (400 bytes) Generic Available, Brand Listed for reference only. Brand may not be covered.

NOTES.gif (377 bytes)NOTES_restrict.gif (372 bytes)

 Notes or
Restrictions

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