Baylor Scott & White Health Plan designates Dexcom and Freestyle Libre as the plan’s preferred continuous glucose monitors (CGMs); all other CGMs are classified as non-preferred. Non-preferred devices may be approved only if the provider submits clinical rationale explaining why preferred devices are inappropriate, the member meets additional clinical coverage criteria in the plan’s table, and use aligns with the member’s coverage document. The policy ties its CGM coverage framework to LCD 33822 (Glucose Monitors), so applicable CMS/BSWHP local coverage requirements will inform final determinations. Expect non-preferred CGM requests to require extra documentation demonstrating medical necessity and contract consistency.
March 2026 Revision: Preferred vs Non-Preferred CGM Designation
This revision clarifies the Plan's formulary approach to continuous glucose monitors (CGMs) by explicitly designating Dexcom and Freestyle Libre as the Plan's preferred CGMs and labeling all other CGMs as non-preferred. The policy reiterates that non-preferred devices may still be considered medically necessary, but only when the provider supplies clinical rationale that preferred devices are inappropriate and the member satisfies any additional clinical coverage criteria.
The document also references external guidance by indicating that the Centers for Medicare & Medicaid Services (CMS) or Baylor Scott & White Health Plan (BSWHP) policy for CGMs is LCD 33822 Glucose Monitors. This ties the Plan's internal preferred/non-preferred distinctions to the applicable local coverage determination for glucose monitors.
Coverage Scope: Which CGMs Are Preferred and Non-Preferred
The policy defines the Plan's coverage classification for continuous glucose monitors with explicit labels: Continuous glucose monitors, Preferred = Dexcom Freestyle Libre and Continuous glucose monitors, Non-Preferred = All other CGMs. This creates a two-tier coverage approach where only the named brands are preferred, and every other CGM product falls into the non-preferred category.
Because preferred status is explicitly limited to Dexcom and Freestyle Libre, devices not matching those brand names will be subject to the Plan's non-preferred review process as detailed elsewhere in the policy.
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