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Coverage for CGMs—and related prior authorization and co-pay issues—remains a key barrier in CGM adoption for primary care practices across the state of Michigan.
Nearly half—46 percent—of all CGM-prescribing encounters included some reported challenge in the cost or insurance coverage of the device, according to case summaries submitted by MCT2D members in the first half of 2022. This likely underestimates the true prevalence of coverage challenges, as the case summaries document only a very small fraction of clinical encounters and may skew toward successful interventions.
The Michigan Collaborative for Type 2 Diabetes is pleased to announce two victories in expanding coverage for CGMs, thanks to partnership and advocacy at a collaborative-scale.
“When insurers and medical professionals are able to collaborate and work together for the good of the patient, positive changes can be made that help drive progress forward,” stated MCT2D Program Manager Jackie Rau, MHSA, PMP.
Access to CGMs has been a key topic of discussion at MCT2D regional and collaborative-wide meetings. Rau is optimistic. “We hope that this work helps to demonstrate to other insurers the benefits of collaboration and we continue to make progress on expanding CGM coverage”
WIN #1: UNITED HEALTHCARE
In Fall 2021, MCT2D informed its members that we had begun working with United Healthcare to determine ways that they could support the work of the collaborative and our members. Together, we identified that removing the prior authorization burden for CGMs would be of high value to the clinicians trying to get these devices to their patients.
United Healthcare and their pharmacy benefit manager OptumRx are generously allowing UHC in-network providers participating in the MCT2D initiative to bypass prior authorization requirements for new prescriptions for preferred CGMs through the UHC Pharmacy benefit managed by OptumRx. The only criteria that a patient will need to meet to receive a CGM is having a diagnosis of type 2 diabetes and a physician participating in MCT2D.
Don’t know if you are enrolled in United PBM OptumRX? look for the lower right-hand section of the front of your ID card.
This change is effective immediately for practices that joined MCT2D in 2021 for new CGM prescriptions. For practices who newly joined MCT2D in 2022, this change will go into effective on 1/1/2023. Please note that this is for prescriptions through the pharmacy only. CGMs ordered through a DME will have to meet additional criteria
Additionally, this only applies to new requests as of the effective date, but patients who have received an approved authorization in the past 12 months through either the Pharmacy or DME benefit will not require a new authorization for a CGM. Patient co-pays will continue to be based on the individual’s plan benefits.
Old Policy before 8/1/2022
Criteria for DME Benefit
1. Diagnosis of diabetes requiring insulin
2. Blood glucose testing at least 4x daily
3. Insulin injections at least 3 x daily OR use of continuous insulin infusion pump
4. Frequent adjustments to treatment regimen necessary based on glucose testing results
5. Documented compliance to physician-directed comprehensive diabetes management program
Updated Policy as of 8/1/2022
Now covered under Pharmacy Benefit for MCT2D Members, with criteria:
- Ordered by an MCT2D member provider
- Patient has T2D diagnosis
DME requirements for non-MCT2D member providers remain unchanged (see above #1-5 criteria)
Who is impacted by this UHC policy change?
Patients with United Healthcare coverage through OptumRx who see a physician who is a contracted UHC Provider participating in MCT2D
Is there anything clinicians on the ground should keep in mind with this change?
Ordering through the DME will result in additional criteria. Clinics who joined as part of Cohort 2 will not have prior authorization removed until 1/1/2023
WIN #2: BCBSM-MANAGED MEDICAID—BLUE CROSS COMPLETE BENEFICIARIES
Blue Cross Complete, a BCBSM-managed Medicaid plan, consulted with MCT2D to revise their criteria for CGM coverage. The MCT2D leadership team drafted recommended changes, which were considered and implemented in their August 2022 policy change. The policy revision removed the restrictive 3x daily blood glucose readings with multiple daily doses of insulin and potentially simplified the documentation criteria for CGM eligibility for BCBSM’s Medicaid beneficiaries.
Old Blue Cross Complete Policy prior to August 2022
- Treatment with insulin via a compatible infusion pump
- Treatment with multiple daily doses of insulin requiring glucose testing 3 or more times per day and one of the following:
- Persistently inadequate glycemic control defined as EITHER: HbA1C ≥ 7% on multiple consecutive readings with one being within the last 3 months OR frequent bouts of hypoglycemia.
- Hypoglycemia unawareness:
- Patient is unable or reluctant to test their blood glucose via traditional glucometer.
- Patient is taking two or more medications to manage their diabetes.
- Patient works with a care team member to improve diet and exercise choices
New Blue Cross Complete Criteria Policy
Now, coverage has been broadly expanded to the following criteria, making CGMs much more accessible:
- Patient must have a diagnosis of diabetes ANDEither Criteria #1 or one of the criteria under #2 must be met:
Criteria #1. Treatment with insulin (type 1 or type 2) OR
Criteria #2. Treatment of Type 2 diabetes with an antihyperglycemic drug without insulin. One of the following must be met:
- Frequent hypoglycemia, hypoglycemia unawareness, or concerns of nocturnal hypoglycemia
- Gaining weight (more than 5 pounds of weight gain in the last 12 months)
- HbA1C ≥ 7%
- Need for medication changes or titration
- Initiation of a lower carbohydrate diet
Who does this impact?
Any Blue Cross Complete patient with type 2 diabetes, especially those ineligible for a CGM under the previous criteria.
Is there anything clinicians on the ground should keep in mind with this change?
There will still be a prior authorization process for BCC patients using a CGM. The prescriber would submit necessary information on the prior authorization form, including the following at a minimum:
- Preferred CGM product (i.e. Dexcom, FreeStyle) and supplies requested.
- Appropriate ICD-10 code for the diabetes diagnosis (i.e. E10.9, E11.9, O24.91, O24.01, O24.11, etc.)
- Justification for use:
- Examples are listed under Criteria #2 in the criteria (i.e. HbA1C ≥ 7%; Frequent hypoglycemia, hypoglycemia unawareness, or concerns of nocturnal hypoglycemia; Patient is taking two or more medications to manage their diabetes, etc.)
- This change applies to the pharmacy side only. The DME benefit remains more restrictive.
See Blue Cross Complete’s updated policy effective 8/1/22:
Download Blue Cross Complete Criteria (PDF)Other Coverage and Prior Auth News
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Support for The Michigan Collaborative for Type 2 Diabetes (MCT2D) is provided by Blue Cross Blue Shield of Michigan as part of the BCBSM Value Partnerships program.
Although Blue Cross Blue Shield of Michigan and MCT2D work collaboratively, the opinions, beliefs and viewpoints expressed by the author do not necessarily reflect the opinions, beliefs and viewpoints of BCBSM or any of its employees.