How To Navigate CGM Insurance Coverage

This content material initially appeared on diaTribe. Republished with permission.

By April Hopcroft

Key takeaways:

• Confirm your CGM protection and prices together with your insurance coverage plan and healthcare supplier. Use the ADCES software for detailed protection info.
• Medicare gives broad CGM protection with some out-of-pocket prices. Medicaid protection varies by state. People who find themselves on each Medicare and Medicaid haven’t any out-of-pocket bills.
• Most industrial insurers cowl CGMs for sort 1 diabetes and for individuals with 2 diabetes on a number of day by day injections or insulin pumps. Protection specifics fluctuate by insurer and state.

So that you’ve determined to get a steady glucose monitor (CGM). You’ve learn up on all of the fashions, familiarized your self with the latest options, and are able to take the subsequent step.

Nevertheless, a problem awaits: Navigating insurance coverage protection.

As a place to begin, remember to verify together with your insurance coverage plan to grasp what protection you might have and what your out-of-pocket prices is perhaps.t. It’s a good suggestion to talk together with your healthcare supplier about insurance coverage protection, too. Your supplier’s workplace could have a selected workers member whose job is to assist individuals navigate insurance coverage protection.

You possibly can take a look at the Affiliation of Diabetes Care and Schooling Specialists (ADCES) CGM insurance coverage protection software. Enter the identify of your insurance coverage, the kind of plan you’ve gotten, and your state of residence to get a abstract of insurance coverage protection for CGMs.

CGM protection when you’ve got sort 1 diabetes

CGM is usually coated for individuals with sort 1 diabetes, no matter sort of insurance coverage.

Medicare and Medicaid protection

The vast majority of individuals within the US identified with diabetes get insurance coverage protection by Medicare or Medicaid, in accordance with Bruce Taylor, senior director of presidency affairs and market entry at Dexcom.

Medicare and Medicaid are authorities insurance coverage packages. Medicare is a nation-wide program that gives well being protection to individuals ages 65 and older. Medicaid is a joint federal and state program that gives well being protection to individuals with restricted earnings and assets.

Medicare additionally gives well being protection to some individuals beneath age 65 with sure disabilities (corresponding to kidney illness requiring dialysis or a transplant) who obtain Social Safety incapacity advantages, no matter earnings degree.

Medicare gives broad protection of CGM, whereas Medicaid protection varies by state.

Medicare protection gives entry to the next CGMs:

• FreeStyle Libre 14-day, Libre 2, and Libre 3 – offered you use the readers to assessment glucose information on some days every month.
• Dexcom G6 and G7
• Guardian 3 and Guardian 4 (when used with an insulin pump system)
  • Be aware that the Guardian Join CGM-only system shouldn’t be coated by Medicare as a result of it doesn’t embody a sturdy receiver to fulfill Medicare profit necessities.
• Eversense E3 implantable sensor

After assembly the yearly Half B deductible (for medical gear protection), individuals with Medicare normally pay 20% of the entire value out of pocket.

Medicaid protection varies from state to state, as do the eligibility necessities to qualify for Medicaid – see in the event you qualify right here.

As of Might 2024, 48 states and Washington, D.C. present some quantity of CGM protection for Medicaid beneficiaries. Presently, 29 of those states cowl CGM for individuals who use insulin by a pharmacy profit (as a substitute of medical profit), which makes it straightforward to get a CGM at a neighborhood pharmacy; sometimes, there is no such thing as a out of pocket value.

People who find themselves twin eligible – which means they’re enrolled in each Medicare and Medicaid – haven’t any out of pocket bills for a CGM.

Industrial insurance coverage by an employer

Industrial insurance coverage, usually known as non-public insurance coverage, is the most typical type of medical health insurance within the US. Most industrial insurers (corresponding to Aetna, Blue Cross Blue Defend, Cigna, Kaiser, and UnitedHealthcare) cowl all the main CGMs for individuals with sort 1 diabetes.

Based on Abbott, most individuals with non-public or industrial insurance coverage pay lower than $40 per 30 days for his or her FreeStyle Libre CGM sensors.

Taylor, from Dexcom, famous that almost all commercially insured customers have a $0 copay for his or her Dexcom CGM. In any other case, the co-pay is normally $20 or much less per 30 days when protection is issued as a pharmacy profit and mixed with financial savings from Dexcom.

CGM protection when you’ve got sort 2 diabetes

CGMs are sometimes coated for individuals with sort 2 who’re taking a number of day by day injections of insulin, use an insulin pump, or have had extreme hypoglycemia (low blood sugar).

One problem that might come up is a prior authorization, which suggests your healthcare supplier or machine firm has to get particular approval out of your medical health insurance firm to pay for the CGM.

If for any motive your insurance coverage supplier decides to disclaim protection for a CGM, know you can attraction and formally ask them to rethink their resolution.

Medicare and Medicaid protection

In 2023, Medicare expanded protection of CGMs to incorporate individuals with sort 2 diabetes who take any sort of insulin, in addition to sort 2s who aren’t taking insulin however have a historical past of hypoglycemia. Since Medicare is a nationwide program, this protection applies all through the US.

Medicaid protection varies from state to state. As of 2023, many states present Medicaid protection for individuals with sort 2 diabetes.

All kids within the US beneath the age of 21 enrolled in any Medicaid program can entry a CGM by the Early and Periodic Screening, Diagnostic, and Remedy (EPSDT) program.

Medicaid packages typically require a previous authorization from a healthcare supplier to obtain CGM protection. Chances are you’ll want to fulfill sure eligibility standards, corresponding to proving a diabetes analysis and exhibiting that you simply often see an endocrinologist, as an illustration.

Industrial insurance coverage by an employer

CGM protection varies relying in your insurance coverage plan, so remember to verify together with your particular person plan for particular info.

• Cigna covers CGM for sort 2 for anybody on a number of day by day injections, long-acting basal insulin, or an insulin pump. Cigna’s protection contains the Senseonics implantable sensor.
• Aetna covers CGM for sort 2 when on a number of day by day injections or insulin pump, and never assembly glycemic targets OR experiencing hypoglycemia or hypoglycemia unawareness.
• UnitedHealthcare covers CGM for adults with sort 2 diabetes who use insulin.
• Blue Cross Blue Defend covers CGMs for adults with sort 2 who use insulin remedy; observe that protection varies by state. In California, as an illustration, CGMs could also be coated beneath pharmacy advantages (with a previous authorization) or by the medical profit at sure sturdy medical gear (DME) corporations.
• Kaiser Permanente covers CGM for adults with sort 2 diabetes who’re on a number of day by day injections or use an insulin pump.

Protection by sturdy medical gear (DME) suppliers

Be aware that for sure insurance policy, you might be eligible for CGM by a sturdy medical gear supplier (corresponding to Byram Healthcare or Superior Diabetes Provide) by your insurance coverage, as CGMs are thought of sturdy medical gear and aren’t coated by the pharmacy profit. If that is so, ask your healthcare supplier to submit a referral for CGM to the DME supplier.

Different methods to acquire a CGM

With out insurance coverage, CGMs – together with the sensor, transmitter, and receiver – can value $1,000 to a number of thousand {dollars} per 12 months.

Usually you will discover coupons for particular pharmacies on GoodRx.com to additional decrease the fee. Many individuals discover the Freestyle Libre CGMs to be essentially the most inexpensive choices, particularly when paying out of pocket.

The everyday out of pocket value for widespread CGMs are:

• FreeStyle Libre 2 and three – about $140 to $150 per 30 days
• Dexcom G6 and G7 – about $170 to $180 per 30 days
• Guardian Sensor 3 – about $180 for a 5 week provide
• Guardian 4 – about $280 for a 5 week provide
• Eversense E3 – about $1,500 to $1,600 per 12 months

In case you are nonetheless unable to entry CGM, there are just a few different choices. Your healthcare group can give you a skilled CGM to put on for a brief time period (normally two weeks) as a strategy to discover ways to improve your time in vary. Alternatively, you possibly can be part of a medical trial for diabetes drugs or know-how, lots of which supply free CGMs all through the examine.

Lastly, there are lots of totally different affected person help packages (PAPs) and financial savings packages accessible on-line.

Dexcom CGMs

Dexcom provides a free insurance coverage advantages verify to see when you’ve got CGM protection – discover extra info within the Dexcom Financial savings Middle.

When you’ve got a excessive copay or plan to pay out of pocket, Dexcom provides a financial savings program, which might help you save over 50% of the usual month-to-month money value.

Dexcom additionally provides a affected person help program to US residents who meet particular poverty line necessities and eligibility standards.

FreeStyle Libre CGMs

When you qualify for the MyFreeStyle program, you’ll be able to entry a free sensor for a two week trial interval.

For individuals with out CGM protection, Abbott’s Client Entry Program ensures you pay not more than $75 per 30 days. This program is for individuals with industrial insurance coverage or cash-paying clients and doesn’t apply to authorities insurance coverage packages like Medicare or Medicaid.

Guardian 3 and 4 sensors

When you don’t have insurance coverage protection in your prescribed CGM, you might be eligible for reductions from Medtronic. To qualify, you could use a number of day by day injections or use an insulin pump, haven’t any insurance coverage protection for Medtronic CGM, and name Medtronic to substantiate your eligibility.

The low cost caps transmitter value as much as $180 per transmitter for a 12-month interval and $60 per field of sensors for every month.

Eversense implantable CGM

Senseonics provides a affected person help program for the Eversense implantable CGM, which has the potential to avoid wasting customers as much as $1,200 per 12 months.

Senseonics just lately expanded this system to incorporate extra commercially insured individuals with diabetes. Via this program, eligible individuals pay solely $99 out of pocket for a limiteless variety of 6-month Eversense E3 methods. This implies you’d pay a mean of $16.50 per 30 days, amounting to lower than $200 out of pocket prices for a whole 12 months of CGM (excluding the prices of insertion and removing).

The underside line

Understanding insurance coverage protection in your CGM can really feel like a frightening job. Happily, broad Medicare and industrial insurance coverage protection for CGM exists for individuals with sort 1 diabetes. Medicare and lots of industrial insurance policy additionally cowl CGMs for individuals with sort 2 diabetes who use insulin.

When you don’t have insurance coverage, CGM corporations supply affected person help packages and different low cost packages to make CGMs extra inexpensive.

“Generally, value shouldn’t be a barrier when you’ve got insurance coverage protection,” Taylor stated. “The largest problem is many occasions individuals don’t perceive what advantages they qualify for.”

When you’ve got questions on CGM protection, seek the advice of your healthcare group to grasp your choices.

*Editor’s observe: This text shouldn’t be a complete checklist of all insurance policy. It was final up to date in Might 2024.