Coverage and Benefit Design
The Centers for Medicare and Medicaid Services (CMS) expanded CGM access to beneficiaries on basal-only insulin and those with a history of level two or three hypoglycemia. Although the Local Coverage Determination (LCD) was originally anticipated to be implemented in July, CMS will enact expanded access to CGM on April 16, 2023. This new coverage policy is aligned with consensus guidelines from the ADA and AACE, which recommend CGM for all patients on insulin at the outset of diagnosis. The new LCD, which was proposed in 2022, also removes the term “daily” as a descriptor for insulin to account for potential FDA approval of weekly insulins in the future.
Learn MorePharmacy professionals and a payer representative convened an expert panel to connect available evidence and the panelists’ extensive experiences on the value of RT-CGM in improving patient quality of life. In addition, the panelists provided practical approaches to bring awareness, accessibility, and the utility of rtCGM to positively impact patient quality of life in practical applications. Managed care and payer professionals will find these real-world insights useful in characterizing the value of RT-CGM in health plan populations when making coverage determinations.
“Real-Time Continuous Glucose Monitoring: Timely Opportunities to Improve Quality of Life.” CGM Live Virtual Crossfire Series Recap. Part 2. Pharmacy Times Continuing Education. August 2021.
Learn MoreAn expert panel composed of pharmacists and a payer professional discussed the value of RT-CGM and the role pharmacists and pharmacy technicians have in optimizing diabetes management. By making RT-CGM available to and allowing pharmacy professionals to work alongside patients, health care stakeholders can leverage the information offered by this technology to optimize diabetes management and mitigate disease impact. The panelists noted that coverage of RT-CGM through the pharmacy benefit facilitates access by allowing patients to fill their prescription directly at community pharmacies. The panelists’ insights are of use to managed care and payer professionals in determining optimal coverage policies for RT-CGM to improve outcomes among members with diabetes.
“Real-Time Continuous Glucose Monitoring: Implications for Pharmacists.” CGM Live Virtual Crossfire Series Recap. Part 1. Pharmacy Times Continuing Education. May 2021.
Learn MoreA roundtable convened by the American Pharmacists Association reviewed the substantial body of evidence demonstrating that CGM is associated with improved glycemic control for patients with both T1D and T2D. Leading experts participating in the roundtable noted that CGM remains underutilized and that disparities in care are evident. One specific barrier to expanded utilization called out by the participants was the lack of an adequate number of providers who offer the service. Developing community pharmacy-based CGM services has been proposed as a logical solution for expanding patient access. Supporting this approach are the abundant data showing that pharmacist involvement in patient care for diabetes improves outcomes and reduces overall costs of care. Managed care and payer professionals will find this in-depth review and discussion valuable for developing their own policies for CGM coverage and access in the pharmacy setting.
American Pharmacists Association Foundation. “Expanding Access to Continuous Glucose Monitoring Technology in Community Pharmacies.” Practices Insights. May 2022.
Learn MoreEffective January 1, 2023, UnitedHealthcare (UHC) is making selected continuous glucose monitoring (CGM) devices and sensors available to Medicare Advantage members at the pharmacy point-of-sale (POS). The systems affected by this change in policy include the Dexcom G6 as well as the FreeStyle Libre 2 and 14-day versions. CGMs were previously only available to UHC Medicare Advantage members through national durable medical equipment (DME) vendors. While availability through DME vendors will remain in place, the plan sought to improve access to CGMs for members by expanding to the pharmacy POS. Managed care decision makers should take note of this change in policy as an example of how national payers are leveraging the pharmacy channel as a means of enhancing coverage and member access to beneficial diabetes technologies.
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Intended Audience: This activity is designed to meet the educational needs of medical directors, registered nurses, pharmacy directors, clinical pharmacists, specialty pharmacists, quality directors, as well as network physicians affiliated with various MCOs, health systems, and other payer organizations.
Credit Available: Up to 0.5 credit hour available for nurses (ANCC), pharmacists (ACPE), and physicians (AMA PRA Category 1 Credit™)
Expiration Date: June 30, 2024
Click Here to Begin!Educational Objectives
- Describe the clinical impact of real-time continuous glucose monitoring on HbA1c, severe hypoglycemia-related events and diabetic ketoacidosis
- Assess health plan opportunities to improve HbA1c and diabetes outcomes through implementation of real-time continuous glucose monitoring interventions for patients with diabetes
- Identify key stakeholders and steps for the delivery of successful quality improvement interventions targeting patients naïve to real-time continuous glucose monitoring
Expert Faculty
Jointly provided by Impact Education, LLC, and Medical Education Resources.
This activity is supported by an independent educational grant from Dexcom, Inc.
Intended Audience: This activity is designed to meet the educational needs of managed care pharmacy directors, clinical pharmacists, quality directors, medical directors, registered nurses, and other managed health care professionals.
Credit Available: Up to 1.0 credit hour available for nurses (ANCC), pharmacists (ACPE), and physicians (AMA PRA Category 1 Credit™)
Expiration Date: January 31, 2024
Click Here to Begin!EDUCATIONAL OBJECTIVES
- Review the latest data supporting the use of rtCGM to improve patient outcomes and reduce resource utilization in T1 and T2D
- Assess the impact of social determinants of health (SDOH) on outcomes in diabetes among low-income and racial/ethnic minority populations
- Describe the role of diabetes technology in increasing patient engagement and self-management across diverse member populations of varying age, race/ethnicity, income, and insurance type
- Discuss the positive impact of electronic prior authorization for rtCGM under the pharmacy benefit in terms of provider administrative burden, access, and total cost of care
EXPERT FACULTY
Monica Peek, MD, MPH, MS
Professor of Medicine
Associate Director
Chicago Center for Diabetes Translational Research
The University of Chicago Medicine
Samir Mistry, PharmD, MBA
Vice President of Pharmacy Strategy & Services
Capital Blue Cross
Kelly Close
Founder, The diaTribe Foundation
President, Close Concerns
Dana McCormick, RPh, FMACP (Moderator)
Director of Pharmacy
Blue Cross Blue Shield of Texas
Jointly provided by Impact Education, LLC, and Medical Education Resources.
This activity is supported by an independent educational grant from Dexcom, Inc.
The National Committee for Quality Assurance (NCQA) is revising its Healthcare Effectiveness Data and Information Set (HEDIS) standardized measures assessing plan performance for 2023. Notably, the 2023 dataset will include a new measure related to diabetes management: the risk-adjusted ratio of observed to expected emergency department visits for hypoglycemia among older adults (aged ≥67 years) with diabetes.
This measure reflects a key component of health plan quality pertaining to the management of diabetes, since older adults are more likely to experience severe hypoglycemia, potentially leading to several adverse outcomes: fall-related events and fractures, increased risk of cardiovascular events, and cognitive decline. Similarly, prevailing clinical practice guidelines for the treatment of older adults with diabetes emphasize the prevention of hypoglycemia as an important outcome. The new HEDIS measure provides an opportunity for health plans to identify older members with diabetes who are at highest risk of hypoglycemia and implement preventive interventions and more intensive management.
Learn MoreKey findings from the symposium at the Academy of Managed Care Pharmacy (AMCP) 2022 Annual Meeting.
Key Takeaways from Dr. Peek:
– rtCGM demonstrated a robust, sustained effect on glycemic control with fewer medications and no increase in insulin doses compared with
blood glucose monitoring (BGM) in the MOBILE RCT
– In the Kaiser analysis, rtCGM initiation reduced healthcare resource utilization for ER/admit due to hypoglycemia by 53%
– Expanded access to rtCGM is warranted based on these findings, particularly in underserved demographics disproportionately affected by
diabetes
Key Takeaways from Dr. Mistry:
– Pharmacy coverage of rtCGM for members with T1 and T2D can result in reduced resource utilization from improvements in clinical
management as well as cost savings for health plans via administrative efficiencies
-rtCGM offers an opportunity for improved outcomes
and proven PMPM savings when covered under the pharmacy benefit
Key Takeaways from Kelly Close:
– CGM represents the single most important tool for improving clinical outcomes and quality of life for people with diabetes
– The lives of people with diabetes have improved exponentially over the past several decades, but continued advancement is possible
with increased access to CGM and the application of more sophisticated measures such as TIR
Jointly provided by Impact Education, LLC, and Medical Education Resources.
This activity is supported by an independent educational grant from Dexcom, Inc.
The American Diabetes Association (ADA) Standards of Medical Care represent the latest evidence-based recommendations for guiding clinical practice. According to the most recent edition of these guidelines, Level A evidence from the MOBILE study supports the use of real time continuous glucose monitoring (rtCGM) in patients with insulin-treated type 2 diabetes (T2D) regardless of regimen. The findings from the MOBILE study likewise demonstrate the value of rtCGM across typically underserved demographics of patients impacted by social determinants of health (SDOH). Taking the ADA recommendations into consideration, payers are formulating coverage policies that facilitate appropriate access to rtCGM, improved outcomes in T2D, and proven per-member-per-month (PMPM) cost savings.
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