Coverage and Benefit Design
Recent News
-
Effective April 1, 2020, Blue KC will also offer coverage for Continuous Glucose Monitors (CGMs) as a pharmacy benefit. While members can continue to utilize their DME benefits instead of pharmacy benefits for CGMs, some brands may eventually no longer be available through DME suppliers. Additionally, the process of obtaining a CGM through the pharmacy is likely a more timely, convenient, and overall better member experience.
-
Effective April 20, 2020 Aetna considers the long-term (greater than 1 week) therapeutic use of continuous glucose monitoring devices medically necessary in adults aged 18 years and older with type 1 diabetes, adults with type 2 diabetes using intensive insulin regimens (multiple (3 or more) daily injections or insulin pump therapy) who are not meeting glycemic targets, and for younger persons with type 1 diabetes.
- Effective April 1st 2020 United Health Care covers long-term CGM for individuals with type 1 or type 2 diabetes when certain criteria are met.
- Effective April 1, 2020, therapeutic continuous glucose monitors (CGMs) will be a benefit of Texas Medicaid for individuals with type 1 or type 2 diabetes who meet medical criteria.
-
Missouri Medicaid’s Pharmacy Program will begin covering the Dexcom G6 Continuous Glucose Monitoring (CGM) System as the preferred CGM system effective April 2, 2020.
CMS-1682R – Therapeutic CGM Category
Source: Centers for Medicare & Medicaid Services
Key Takeaway: Recognizing the value of CGM, and in response to the recent FDA approvals of CGM as a replacement for fingersticks, CMS created a benefit category for therapeutic CGMs, providing for coverage of these devices under the following conditions:
- The beneficiary has diabetes mellitus (Refer to the “ICD-10 Codes that are Covered” section of the LCD-related Policy Article for applicable diagnoses); and,
- The beneficiary has been using a BGM and performing frequent (four or more times a day) testing; and,
- The beneficiary is insulin-treated with multiple (three or more) daily injections of insulin or a Medicare-covered continuous subcutaneous insulin infusion (CSII) pump; and,
- The beneficiary’s insulin treatment regimen requires frequent adjustment by the beneficiary on the basis of BGM or CGM testing results; and,
- Within six (6) months prior to ordering the CGM, the treating practitioner has an in-person visit with the beneficiary to evaluate their diabetes control and determined that criteria (1-4) above are met; and,
- Every six (6) months following the initial prescription of the CGM, the treating practitioner has an in-person visit with the beneficiary to assess adherence to their CGM regimen and diabetes treatment plan.
Current Eligibility Requirements for CGM Coverage Are Harmful, Costly, and Unjustified
Source: Diabetes Technology and Therapeutics
Key Takeaway: There is growing and compelling evidence that CGM coverage should be offered to all patients who can benefit from this technology regardless of diabetes type and history of SMBG use. The current restrictions, which are based on outdated evidence and questionable assessments, are not supported in the literature. Moreover, they ignore the burden frequent SMBG places on individuals. Given the growing prevalence of diabetes, the persistent preponderance of individuals with suboptimal glycemic control, and the exorbitant and largely preventable cost of diabetes complications, opinion-based constraints should not continue to supplant evidence-based clinical management.
Medicaid Coverage
*Map updated April 1, 2020
Medicaid Policies
- Illinois Department of HealthCare and Human Services Pharmacy
- Washington State Health Care Authority
- Vermont Medicaid Pharmacy; Vermont Medicaid Medical
