WHA

Continuous Glucose Monitors, Sensors, and Transmitters - PA, NF

Indications for Prior Authorization

Criteria

Dexcom Products*

*If patient meets criteria above, please approve all CGM components at NDC list “PFEHBCGMPA”

Prior Authorization (Initial Authorization)

Length of Approval: 12 Month(s)

  • ALL of the following:
    • Diagnosis of diabetes mellitus
      • AND
    • Patient is adherent to current diabetes treatment plan and participates in ongoing diabetes education and support
      • AND
    • ONE of the following:
      • Patient is being treated with insulin
        • OR
      • Patient has a history of problematic hypoglycemia with at least one of the following:
        • Recurrent (more than one) level 2 hypoglycemic events (glucose less than 54mg/dL (3.0mmol/L)) that persist despite multiple (more than one) attempts to adjust medication(s) and/or modify the diabetes treatment plan
        • Patient has a history of one level 3 hypoglycemic event (glucose less than 54mg/dL (3.0mmol/L)) characterized by altered mental and/or physical state requiring third-party assistance for treatment of hypoglycemia
Dexcom Products*

*If patient meets criteria above, please approve all CGM components at NDC list “PFEHBCGMPA”

Prior Authorization (Reauthorization)

Length of Approval: 12 Month(s)

  • ONE of the following:
    • Patient demonstrates positive clinical response as evidenced by ONE of the following:
      • Improvement in glycemic control (e.g., lower and/or maintain A1C levels)
      • Reduction or improvement in hypoglycemic events
      OR
    • Patient is being assessed by the prescriber for adherence to their CGM regimen and diabetes treatment plan
All Other Continuous Glucose Monitors, Sensors, and Transmitters*

*If patient meets criteria above, please approve all CGM components at GPI list “CGMPA”

Prior Authorization (Initial Authorization)

Length of Approval: 12 Month(s)

  • ALL of the following:
    • Diagnosis of diabetes mellitus
      • AND
    • Patient is adherent to current diabetes treatment plan and participates in ongoing diabetes education and support
      • AND
    • ONE of the following:
      • Patient is being treated with insulin
        • OR
      • Patient has a history of problematic hypoglycemia with at least one of the following:
        • Recurrent (more than one) level 2 hypoglycemic events (glucose less than 54mg/dL (3.0mmol/L)) that persist despite multiple (more than one) attempts to adjust medication(s) and/or modify the diabetes treatment plan
        • Patient has a history of one level 3 hypoglycemic event (glucose less than 54mg/dL (3.0mmol/L)) characterized by altered mental and/or physical state requiring third-party assistance for treatment of hypoglycemia
      AND
    • Minimum 90 day trial within the last 180 days, to Dexcom Products (Applies to all products except Dexcom)
All Other Continuous Glucose Monitors, Sensors, and Transmitters*

*If patient meets criteria above, please approve all CGM components at GPI list “CGMPA”

Prior Authorization (Reauthorization)

Length of Approval: 12 Month(s)

  • ONE of the following:
    • Patient demonstrates positive clinical response as evidenced by ONE of the following:
      • Improvement in glycemic control (e.g., lower and/or maintain A1C levels)
      • Reduction or improvement in hypoglycemic events
      OR
    • Patient is being assessed by the prescriber for adherence to their CGM regimen and diabetes treatment plan
    AND
  • Minimum 90 day trial to Dexcom Products (Applies to all products except Dexcom)
Continuous Glucose Monitors, Sensors, and Transmitters*

*If patient meets criteria above, please approve all CGM components at GPI list “CGMPA”

Non Formulary

Length of Approval: 12 Month(s)

  • ALL of the following:
    • Diagnosis of diabetes mellitus
      • AND
    • Patient is adherent to current diabetes treatment plan and participates in ongoing diabetes education and support
      • AND
    • ONE of the following:
      • Submission of medical records (e.g., chart notes) or paid claims confirming patient is being treated with insulin
        • OR
      • Submission of medical records (e.g., chart notes) confirming patient has a history of problematic hypoglycemia with at least one of the following:
        • Recurrent (more than one) level 2 hypoglycemic events (glucose less than 54mg/dL (3.0mmol/L)) that persist despite multiple (more than one) attempts to adjust medication(s) and/or modify the diabetes treatment plan
        • Patient has a history of one level 3 hypoglycemic event (glucose less than 54mg/dL (3.0mmol/L)) characterized by altered mental and/or physical state requiring third-party assistance for treatment of hypoglycemia
      AND
    • Submission of medical records (e.g., chart notes) or paid claims confirming minimum 90 day trial within the last 180 days, to Dexcom products (Applies to all products except Dexcom)

  • Guideline ID
    GL-143563

  • Formulary
    EHB

  • Effective date
    Mar 15, 2024

  • P&T approval date

P & T Revisions

2024-02-26, 2024-01-17, 2023-12-18, 2023-12-14, 2023-11-06, 2023-10-16, 2023-08-27, 2023-07-05, 2023-06-23, 2023-04-21, 2023-01-21, 2022-09-16, 2022-09-12, 2022-04-14, 2021-09-10, 2021-07-20

  1. CMS. Provider compliance tips for glucose monitors & diabetic accessories/supplies. CMS Website. Available at: https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?lcdid=33822. Accessed March 21, 2023.
  2. American Diabetes Association. Diabetes Care. Available at Volume 45 Issue Supplement_1 Diabetes Care | American Diabetes Association (diabetesjournals.org). Available at https://diabetesjournals.org/care/issue/45/Supplement_1. Accessed April 12, 2022.
  3. BigFoot Unity PDF. Available at: https://f.hubspotusercontent40.net/hubfs/5085144/PDFs/Bigfoot%20Unity%E2%84%A2%20System%20User%20Guide.pdf. Accessed May 23, 2023.
  1. People who have been using continuous glucose monitoring, continuous subcutaneous insulin infusion, and/or automated insulin delivery for diabetes management should have continued access across third party payers. Interruption of access to CGM is associated with a worsening of outcomes, therefore, it is important for individuals on CGM to have consistent access. [2]
  • 2024-02-26: update guideline
  • 2024-01-17: update guideline.
  • 2023-12-18: update product list
  • 2023-12-14: update guideline
  • 2023-11-06: update guideline
  • 2023-10-16: No criteria changes. Attached EHB formulary to guideline.
  • 2023-08-27: update guideline
  • 2023-07-05: 2023 Annual Review
  • 2023-06-23: update guideline
  • 2023-04-21: Update Guideline
  • 2023-01-21: update guideline
  • 2022-09-16: update guideline
  • 2022-09-12: guideline update
  • 2022-04-14: Update guideline
  • 2021-09-10: added GPIs for target products
  • 2021-07-20: New program.