Continuous Glucose Monitoring (CGM) System Utilization Management Update

To support appropriate utilization management, we continually review relevant clinical guidelines and reassess our requirements. Utilization management criteria for Freestyle and Dexcom CGMs will be updated for some of our formularies effective September 11, 2023.  

What are CGMs?
A CGM is a wearable system that monitors glucose levels throughout the day and can help some diabetics improve their blood sugar control or prevent or identify low blood sugar events. CGM systems can be comprised of up to three components:

1. Sensor – contains a wire catheter that is inserted under the skin to measure glucose level.
2. Transmitter – attaches to the sensor to transmit data wirelessly to the display device; may be combined with the sensor for some systems.
3. Display device –  displays the measured glucose levels; may be a stand-alone reader/receiver specific for that CGM or can use a smartphone by downloading software application.

What is changing?

• The prior authorization (PA) criteria for Dexcom and Freestyle CGMs will be updated to allow coverage for all members currently utilizing insulin. This is based on recommendations in the 2023 American Diabetes Association guidelines that CGMs be offered to individuals using intensive insulin therapy as well as basal insulin users that are capable of using the devices safely. “Smart PA” technology will be utilized to allow coverage for members with an insulin claim in the preceding 180 days without a formal PA request needing to be submitted.
• The PA criteria will also allow coverage for members using non-insulin anti-diabetic medication that have frequent recurring episodes of hypoglycemia (less than 70 mg/dL) despite appropriate modifications to medication, hypoglycemia unawareness, episodes of ketoacidosis, or hospitalization for uncontrolled glucose levels.
• The PA requirement will be moved to the sensor component of the CGM system. This change is being made as the sensor is the one component of every CGM system needed by all utilizers.

What is staying the same?

• Continuation of coverage for members currently utilizing Freestyle and Dexcom CGMs will be provided.
• Quantity limits will remain the same (see table below).