Does Insurance Cover CGM for Type 2 Diabetes and What the Options Are

Insurance coverage for Continuous Glucose Monitors (CGMs) varies depending on the type of diabetes you have. If you have type 2 diabetes, you may be eligible for insurance coverage for a CGM, but it depends on your individual circumstances.

Some insurance plans cover CGMs for type 2 diabetes, but you'll need to meet certain criteria. This typically includes having a history of hypoglycemia or experiencing significant glycemic variability.

The cost of a CGM can be high, with prices ranging from $500 to over $1,000 per year. However, if you have insurance coverage, you may be able to get a significant discount or even have the cost covered entirely.

In order to get insurance coverage for a CGM, you'll typically need to get a prescription from your doctor and meet certain medical criteria. This may include having a certain level of glycated hemoglobin (A1C) or experiencing symptoms such as frequent urination or blurred vision.

Insurance coverage for CGMs can vary depending on your insurance provider. Most commercial health insurers will cover CGMs for people living with diabetes, but Medicare coverage requires meeting specific requirements.

Medicare will typically cover CGMs for patients with type 1 or type 2 diabetes, but they must have received proper training, use insulin, or have a history of problematic hypoglycemia. Additionally, patients must meet with their healthcare provider every six months to confirm they're following their CGM regimen.

If you have Medicaid, coverage varies by state, with some states following Medicare guidelines and others having more lenient criteria. To determine eligibility, contact your state's Medicaid office or healthcare provider.

Most commercial health insurers will cover CGM systems for people living with diabetes, but coverage can vary between providers.

To qualify for CGM coverage under Medicare, patients must have a type 1 or type 2 diabetes diagnosis, received proper training for CGM usage, plan to use their CGM in keeping with FDA indications, use insulin and/or have a history of problematic hypoglycemia, and have completed an in-person or telehealth visit with their healthcare provider within six months of ordering their CGM.

Medicare will typically cover continuous glucose monitoring systems and related supplies, but patients must meet specific requirements to qualify. These requirements include having a type 1 or type 2 diabetes diagnosis, received proper training for CGM usage, plan to use their CGM in keeping with FDA indications, use insulin and/or have a history of problematic hypoglycemia, and have completed an in-person or telehealth visit with their healthcare provider within six months of ordering their CGM.

Here are some private insurance plans that offer coverage for CGMs:

To determine CGM coverage, follow these steps:

1. Check your insurance policy or contact your insurer to ask about coverage for CGMs for Type 2 diabetes.

2. Ask about preferred brands or models.

3. Find out about out-of-pocket costs, such as copays or deductibles.

CGMs are considered durable medical equipment (DME) and are subject to the same deductibles and copays as other types of DME. To maximize coverage, it's essential to comply with your insurance company's requirements and provide them with the necessary information to support your case.

Some CGMs, like the Dexcom G6 or Freestyle Libre, are more commonly covered than others. Devices categorized as "therapeutic CGMs" (those approved for treatment decisions without fingersticks) are more likely to be reimbursed.

Insurance companies have different marketing strategies to promote their coverage plans. Some may highlight the benefits of CGMs for Type 2 diabetes, while others may focus on the costs and limitations of coverage.

Coverage for CGMs varies widely between insurance plans, making it essential for individuals to research and understand their options. Insurance companies may use various tactics to make their plans more appealing, such as offering discounts or promotions for new customers.

To effectively market their coverage plans, insurance companies must consider the key factors that influence insurance coverage, including the type of diabetes and the individual's medical history. This information can help them tailor their marketing efforts to specific groups and increase the chances of getting approved for coverage.

Medicare will typically cover continuous glucose monitoring systems and related supplies, but you'll need to meet specific requirements.

To qualify for CGM coverage under Medicare, you must have a type 1 or type 2 diabetes diagnosis and have received proper training for CGM usage, as indicated by a prescription.

You'll also need to use insulin and/or have a history of problematic hypoglycemia, including multiple level 2 hypoglycemic events and at least one level 3 hypoglycemic event.

To maintain Medicare insurance coverage for continuous glucose monitoring systems and supplies, you must meet with your healthcare provider every six months after receiving your prescription.

Medicare has provided coverage for CGM systems since 2017, provided they are classified as “therapeutic” devices.

The Centers for Medicare & Medicaid Services (CMS) have recently relaxed Medicare’s other coverage criteria somewhat.

To be eligible for Medicare coverage, you must have a diagnosis of either type 1 or type 2 diabetes, use a traditional blood glucose meter and test blood sugar levels four or more times a day, be treated with insulin injections or insulin pumps, and require frequent adjustments to your insulin regimen.

Medicare will cover the following CGM devices: Dexcom G6, Dexcom G7, FreeStyle Libre 3 System, and FreeStyle Libre 2 System.

These devices are typically worn on the upper arm or torso and can transmit blood glucose readings every few minutes to a reader or a smartphone app.

The FreeStyle Libre Systems are a line of CGMs that are typically worn on the skin of the upper arm for up to 14 days.

Here are the CGM devices that are currently covered by Medicare:

If you're denied for coverage the first time around, don't give up – you can go through the appeal process and may be approved on the second, third, or even fourth round of appeals.

Dexcom's G7 CGM System can be expensive for those without insurance coverage, but they offer a special rate of $89/month through certain suppliers.

People with commercial insurance may pay a maximum of $65 for a FreeStyle Libre 2 reader and $75/month for sensors at participating pharmacies.

The actual cost could differ based on how much your insurance covers, so it's essential to check with your insurance provider for specific details.

Dexcom's G7 CGM System can be added to commercial insurance plans on a weekly basis, making it more accessible to those who need it.

For those without insurance coverage, Dexcom offers a special rate of $89/month through certain suppliers.

People with commercial insurance typically pay a maximum of $65 for a FreeStyle Libre 2 reader.

The monthly cost for sensors at participating pharmacies is $75, but actual costs may vary based on insurance coverage.

Working with a Durable Medical Equipment (DME) supplier can make the process of getting a CGM device much smoother. Insurance companies often have specific suppliers they work with to provide CGMs.

You can expect the supplier to handle much of the paperwork, making the process less overwhelming for you. This is a huge advantage of working with a DME supplier.

Medicaid coverage for CGMs varies by state, so it's essential to contact your state's Medicaid office or healthcare provider to determine eligibility and understand any documentation requirements.

Some states follow Medicare guidelines, which require intensive insulin therapy and proof of medical necessity. This can make it more challenging to get coverage, but it's not impossible.

If Medicaid isn't an option, you may want to explore alternative options, such as private insurance. Most commercial insurers cover CGM systems for people with type 1 diabetes, and some may also cover them for those with type 2 diabetes.

Medicaid coverage for diabetes varies by state. Some states have specific requirements for coverage, such as intensive insulin therapy and proof of medical necessity.

If you're on Medicaid, you'll want to contact your state's Medicaid office or healthcare provider to determine eligibility and understand any documentation requirements.

Medicaid's coverage for Continuous Glucose Monitors (CGMs) can be a game-changer for people with Type 2 diabetes. A CGM can be particularly beneficial for individuals who use multiple daily insulin injections, experience frequent hypoglycemia or hyperglycemia, or struggle to maintain target glucose levels with other methods.

However, obtaining a CGM for Type 2 diabetes often hinges on whether insurance deems it "medically necessary."

You can use pre-tax dollars from a Health Savings Account (HSA) or a Flexible Spending Account (FSA) to pay for medical expenses, including CGM-related costs.

HSAs and FSAs can be used to cover medical devices, such as sensors, transmitters, and readers, even if they're not covered by your insurance. Be sure to keep receipts and documentation for tax purposes.

Prior authorization is a necessary step for getting insurance approval for a Continuous Glucose Monitor (CGM). This process can be lengthy, taking anywhere from a few days to several weeks, depending on your insurer and the completeness of your documentation.

To obtain prior authorization, you'll need to submit a detailed request from your doctor. This request should demonstrate medical necessity with supporting evidence, such as glucose logs and treatment history.

The approval process can be influenced by the completeness of your documentation, so be sure to gather all required information before submitting your request.

If your insurance denies coverage for a Continuous Glucose Monitor (CGM), don't worry, there are still options to make these devices more affordable.

You can pay directly for a CGM, although this can be costly. Many CGM manufacturers offer rebates, discounts, or financing options, which can help make the device more accessible.

Nonprofit organizations, such as the American Diabetes Association, may offer resources or financial aid for diabetes management tools, including CGMs.

Some community health clinics provide free or low-cost diabetes care supplies, including CGMs, which can be a great option for those who need assistance.

If you're looking for more information on how to navigate insurance coverage for a CGM, here are some options to consider:

A continuous glucose monitor (CGM) is a wearable medical device that tracks blood sugar levels throughout the day and night.

CGMs are inserted under the skin, providing continuous readings that are sent to a monitor or smartphone, allowing users to see trends and make informed decisions about their diabetes care.

These devices can reduce the frequency of fingerstick tests, which is a great benefit for people with diabetes who may be doing multiple tests a day.

CGMs can also help identify blood sugar patterns, which can be really helpful in managing diabetes.

They can even prevent dangerous highs and lows, which is crucial for people with diabetes who may be at risk of experiencing these complications.

CGMs can improve overall diabetes management, making it easier for people to take control of their health.

Here are some of the key benefits of CGMs: