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Simplifying Continuous Glucose Monitors Insurance Complexities

Simplifying Continuous Glucose Monitors Insurance Complexities

It can seem overwhelming to figure out what insurance covers your CGM. Thankfully, individuals with type 1 diabetes can obtain comprehensive coverage for CGM through Medicare and commercial insurance. For individuals with type 2 diabetes who use insulin, Medicare and numerous commercial insurance companies also pay for Continuous Glucose Monitors or CGMs.

CGM manufacturers provide patient assistance programs and other discount schemes to lower the cost of Continuous Glucose Monitors or CGMs if you don’t have insurance.

“Generally speaking, if you have insurance coverage, cost shouldn’t be an obstacle,” Taylor stated. “The largest problem is that people frequently don’t know what benefits they are eligible for.”

If You Have Type 1 Diabetes, Coverage For CGM

Individuals with type 1 diabetes are typically eligible for CGM regardless of their insurance type.

There are two government insurance programs: Medicare and Medicaid. People 65 and older can receive health coverage through Medicare, a national program. People with low incomes and resources can get health coverage through Medicaid, a combined federal-state program.

Bruce Taylor, senior director of government affairs and market access at Dexcom, states that the majority of Americans with diabetes receive insurance coverage through Medicare or Medicaid.

Regardless of income level, Medicare also offers health coverage to select individuals under 65 with specific conditions (such as renal disease requiring dialysis or a transplant) who get Social Security disability benefits.

While Medicaid coverage varies by state, Medicare offers comprehensive coverage for CGM.

Medicare Benefits

The following Continuous Glucose Monitors or CGMs are accessible to those with Medicare coverage:

  • FreeStyle Libre 14-day, Libre 2-day, and Libre 3-day, as long as you utilize the readers to check your blood sugar levels on a few days every month.
  • Dexcom G6 and G7 Guardians 3 and 4 (when utilized in conjunction with an insulin delivery device)
  • Keep in mind that Medicare does not cover the Guardian Connect CGM-only system since it lacks a durable receiver that satisfies Medicare benefit requirements.
  • The implanted sensor Eversense E3
  • For medical equipment coverage, Medicare beneficiaries typically pay 20% of the total cost out of cash after meeting the annual Part B deductible.

Medicaid Benefits

Medicaid coverage and eligibility standards differ from state to state. Check your eligibility for Medicaid here.

  • By May 2024, Medicaid recipients could receive some CGM coverage from 48 states as well as Washington, D.C. At the moment, 29 of these states provide pharmacy benefits (rather than health benefits) for CGM for insulin users, making it simple to obtain a CGM at a nearby drugstore; usually, there is no out-of-pocket expense.
  • Dual-eligible individuals—that is, enrolled in both Medicare and Medicaid—do not incur any out-of-pocket costs for a continuous glucose monitor.

Commercial Insurance Via a Company

  • In the US, commercial insurance, also referred to as private insurance, is the most popular type of health insurance. For individuals with type 1 diabetes, the majority of commercial insurers (including Aetna, Blue Cross Blue Shield, Cigna, Kaiser, and UnitedHealthcare) cover all of the major Continuous Glucose Monitors or CGMs.
  • The majority of individuals with private or business insurance, according to Abbott, pay less than $40 a month for their FreeStyle Libre CGM sensors.
  • The majority of commercially insured users of Dexcom Continuous Glucose Monitors or CGMs have a $0 copay, according to Taylor of Dexcom. If not, the co-pay is often $20 or less each month when Dexcom savings are paired with coverage provided as a pharmacy benefit.

If You Have Type 2 Diabetes, Coverage For CGM

People with type 2 diabetes who use an insulin pump, take numerous daily insulin injections, or have experienced severe hypoglycemia (low blood sugar) are usually eligible for coverage of Continuous Glucose Monitors or CGMs.

A potential obstacle is prior authorization, which implies that for your health insurance company to pay for the CGM, your healthcare professional or the device manufacturer needs to obtain special permission.

You have the right to file an official appeal and request that your insurance company reevaluate its decision if, for any reason, it chooses not to cover a CGM.

Medicare Benefits

  • Medicare extended coverage for continuous glucose monitors (CGMs) in 2023 to cover those with type 2 diabetes who take insulin, regardless of kind, as well as those without insulin who have a history of hypoglycemia.
  • Medicare is a nationwide program, therefore this coverage is available everywhere in the United States.

Medicaid Benefits

  • The coverage of Medicaid differs between states. By 2023, Medicaid will cover persons with type 2 diabetes in many states.
  • Via the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) program, any kid in the US under the age of 21 registered in any Medicaid program is eligible for a CGM.
  • For CGM coverage under Medicaid programs, a healthcare provider’s prior authorization is typically required. To be eligible, you might need to fulfill certain requirements, like demonstrating that you see an endocrinologist regularly and providing documentation of your diabetes diagnosis.

Commercial Insurance Via a Company

  • Your insurance plan will determine the exact details of CGM coverage, so be sure to check with them directly.
  • For individuals requiring long-acting basal insulin, insulin pumps, or several daily injections, Cigna provides coverage for CGM for type 2. Senseonics implanted sensor is covered by Cigna.
  • When a type 2 diabetic is receiving several daily injections or an insulin pump, not meeting their glycemic objectives, or having hypoglycemia or hypoglycemia unawareness, Aetna provides coverage for CGM.

UnitedHealthcare Pays for CGM: Conditions

  • When An Adult With Type 2 Diabetes Uses Insulin, UnitedHealthcare Pays for CGM
  • For persons with type 2 diabetes who utilize insulin therapy, Blue Cross Blue Shield provides coverage for CGMs; however, coverage differs by state. For example, in California, certain durable medical equipment (DME) firms may cover CGMs through their medical plan or pharmaceutical coverage (with prior authorization).
  • In persons with type 2 diabetes who use an insulin pump or require several daily injections, Kaiser Permanente provides coverage for CGM.

Coverage Via Providers of Durable Medical Equipment (DME)

Because CGMs are classified as durable medical equipment and are not covered by the pharmacy benefit, you may be able to obtain a CGM via your insurer through a durable medical equipment supplier (like Byram Healthcare or Advanced Diabetes Supply). In such a scenario, request that your physician recommend CGM to the DME supplier.

Alternatives For Getting a CGM

Continuous Glucose Monitors or CGMs, which include the sensor, transmitter, and receiver, can cost anywhere from $1,000 to several thousand dollars annually without insurance.

On GoodRx.com, you can frequently find coupons for particular pharmacies to further reduce the price. When paying out of pocket, a lot of individuals find the Freestyle Libre Continuous Glucose Monitors or CGMs to be the most economical choice.

Explore More Dexcom’s Stelo OTC for Uninsured Patients: Continuous Glucose Monitors

Common CGM Out-Of-Pocket Expenses

Common CGM out-of-pocket expenses are as follows:

  • FreeStyle Libre 2 and 3: monthly costs range from $140 to $150.
  • Dexcom G6 and G7: monthly costs range from $170 to $180.
  • Guardian Sensor 3: A five-week supply costs roughly $180.
  • About $280 gets you a five-week supply of Guardian 4.
  • Eversense E3 costs between $1,500 and $1,600 annually.

There are a couple more choices if you are still unable to use CGM. To help you learn how to extend your time in range, your healthcare team may offer you a professional CGM to wear for a short while (about two weeks). A clinical trial for diabetic drugs or technologies is an alternative; many of them provide free Continuous Glucose Monitors or CGMs for the duration of the trial. Finally, a plethora of online patient assistance programs (PAPs) and savings schemes are accessible.

Dexcom Continuous Glucose Meters

To find out if you have CGM coverage, Dexcom provides a free insurance benefits check; further details are available in the Dexcom Savings Center.

Dexcom offers a savings program that can help you save more than 50% of the typical monthly cash price if you have a large copay or want to pay out of pocket.

For US citizens who fulfill certain eligibility conditions and poverty line standards, Dexcom also provides a patient assistance program.

Liberate Style Continuous Glucose Monitors or CGMs

You can test a free sensor for two weeks if you are eligible for the MyFreeStyle program.

Abbott’s Consumer Access Program guarantees monthly payments of no more than $75 for those without coverage for a CGM. This scheme does not apply to government insurance programs like Medicare or Medicaid; it is only for those with commercial insurance or cash-paying clients.

Guardian Sensors Three and Four

Medtronic may offer you savings if your insurance does not cover the cost of your prescribed CGM. You must utilize an insulin pump or numerous daily injections, not have insurance that covers Medtronic CGM, and contact Medtronic to verify your eligibility to be eligible.

The discounted capped transmitter costs up to $180 per unit for a full year and $60 per month for each package of sensors.

Implantable Eversense Continuous Glucose Monitors

For the Eversense implantable CGM, Senseonics provides a patient assistance program that might save consumers up to $1,200 annually.

More diabetics with commercial insurance are now part of the program because of Senseonics’ recent expansion. Those who qualify for this program can purchase an infinite number of 6-month Eversense E3 systems for just $99 out of pocket. This implies that assuming you pay the insertion and removal charges separately, you would pay an average of $16.50 per month for a year of CGM, or less than $200 out of pocket.

Important Conclusions

  • Check with your insurance company and healthcare provider about the costs and coverage of your Continuous Glucose Monitors. For comprehensive coverage details, use the ADCES tool.
  • Medicare offers comprehensive Continuous Glucose Monitors or CGMs coverage, albeit at some personal expense. The coverage of
  • Medicaid differs by state. Individuals who get both Medicaid and Medicare do not have any out-of-pocket costs.
  • When a person with type 1 diabetes needs numerous daily injections or an insulin pump, most commercial insurers will pay for Continuous Glucose Monitors or CGMs. Details of the coverage differ by state and insurance.
  • You have decided to purchase continuous glucose monitors (CGMs). After familiarizing yourself with the latest features and reading up on all the models, you’re prepared to move on.

But there’s a Problem Ahead: Figuring Out Insurance Coverage

Checking with your insurance plan will help you determine what coverage you may have and what your potential out-of-pocket expenses are. It is advisable to discuss insurance coverage with your healthcare professional as well. There may be a specialized employee in your provider’s office whose responsibility it is to guide clients through insurance coverage.

The Continuous Glucose Monitors insurance coverage tool is available through the Association of Diabetes Care and Education Specialists (ADCES). To obtain a summary of your insurance coverage for Continuous Glucose Monitors, enter the name of your insurer, the kind of plan you have, and your state of residence.