CurrentFlorida BluePolicy N/A

Prior authorization process for continuous glucose monitors (CGMs) and supplies

Governs prior authorization submission and dispensing process for CGMs and related supplies for Florida Blue Medicare Advantage (BlueMedicare HMO and PPO) members, affecting prescribers, pharmacies, and prior authorization workflows.

Policy Summary

PayerFlorida Blue

PolicyPrior authorization process for continuous glucose monitors (CGMs) and supplies

Policy CodePolicy N/A

Change TypeDispensing location updateAvaility authorization workflow revised

Effective DateJan 1, 2023

Next Review DateN/A

Key ActionSubmit prior authorization in Availity and include the CGM product 11-digit NDC so the authorization can be processed and the prescription sent to the member's in-network pharmacy.

SourceLink

POLICY UPDATE CHANGES

CGMs and supplies for BlueMedicare HMO and PPO members can be dispensed by any in-network retail or home delivery pharmacy instead of through CareCentrix.

Prior authorizations for CGMs and supplies are handled through Florida Blue Medicare and streamlined via Availity with an NDC entry requirement.

When CGMs are used with an insulin pump provided at the same time, initial authorization and fill may be obtained through CareCentrix; subsequent refills are from in-network pharmacies without an additional authorization.

14 daysstandard medical necessity review turnaround time

11-digit NDCrequired product identifier in Availity

Apr 15, 2023

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Coverage Criteria for CGMs and Supplies

Coverage criteria for CGMs and supplies

Covered for BlueMedicare HMO and PPO members when prior authorization for medical necessity is obtained and the CGM product 11‑digit NDC is provided in Availity; dispensing occurs via in‑network retail or home delivery pharmacies (see insulin pump exception).

ALL of the following must be met

Prior authorization: Authorization for medical necessity is required for new and existing patients; include the CGM product 11‑digit NDC when submitting the request in Availity.
Availity entry: When an HCPCS code from the CGM list (E2103, A4239, E2102, A4238) is entered, Availity will prompt selection of an unclassified DME product code and require entry of the 11‑digit NDC in the 'CGM Product Code' field; users may search the NDC field by brand.
Medical necessity review time: Medical necessity review turnaround is up to 14 days (standard).
Dispensing after authorization: Once authorized, send the prescription for CGMs and maintenance supplies to the member's chosen in‑network retail or home delivery pharmacy; routine dispensing through CareCentrix is no longer used.

EXCEPTION

Insulin pump with adjunctive CGM: If an insulin pump and adjunctive CGM are provided together, the initial authorization and fill may be obtained through CareCentrix.
Subsequent refills for adjunctive CGM provided with an insulin pump: After the initial CareCentrix fill, subsequent CGM refills are dispensed via in‑network pharmacies without an additional authorization for the duration of the approved authorization.

NOTES

Preferred devices and CMS coverage: Availity will display Medicare preferred brands (preferred CGMs are FreeStyle Libre 2 and Dexcom); FreeStyle Libre 3 is not covered by CMS as indicated.

HCPCS codes referenced

E2103 — Non‑Adjunctive CGM receiver/monitor; A4239 — Non‑Adjunctive CGM supplies; E2102 — Adjunctive CGM receiver/monitor; A4238 — Adjunctive CGM supplies.

Coding and Product Identifiers

CGM HCPCS/DME codes referencedHCPCS

E2103	Non-Adjunctive CGM Receiver/monitor
A4239	Non-Adjunctive CGM Supplies
E2102	Adjunctive CGM Receiver/monitor
A4238	Adjunctive CGM Supplies

Sample CGM product NDCsNDC

08627009111	DEXCOM G6 MIS RECEIVER
57599080000	FREESTY LIBRE KIT 2 SENSOR
08627003011	DEXCOM G4 PLATINUM PEDIATRIC RECEIVER KIT
08627003021	PEDIATRIC RECEIVER KIT
08627003031	DEXCOM G4 PLATINUM PEDIATRIC RECEIVER KIT
08627006011	DEXCOM G4 PLATINUM PEDIATRIC RECEIVER KITISHARE
08627006021	DEXCOM G4 PLATINUM PEDIATRIC RECEIVER KITISHARE
08627006031	DEXCOM G4 PLATINUM PEDIATRIC RECEIVER KITISHARE
08627002011	DEXCOM G4 PLATINUM RECEIVER KIT
08627002021	DEXCOM G4 PLATINUM RECEIVER KIT

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inv-04: medical necessity review time

Standard medical necessity review timeMedical necessity review can take up to 14 days (standard turnaround).

Prior authorization requirementAuthorization for medical necessity is required for new and existing patients; include the CGM product 11-digit NDC in Availity.

Status trackingProviders can check the status of a review in Availity.

Post-approval prescription routingOnce approved, prescriptions for CGM supplies can be sent to the member's in-network retail or mail-order pharmacy for processing.

Provider Submission and Dispensing Actions

Prior Authorization

Submit prior authorization in Availity with NDC

Submit an authorization for medical necessity in Availity for new and existing patients and include the CGM product 11-digit NDC so the member can fill the CGM supplies at a local or mail-order pharmacy. Medical necessity review can take up to 14 days; once approved, send the prescription to the member's in-network retail or home delivery pharmacy.

Include the 11-digit NDC in the authorization request to enable automated processing and pharmacy dispensing.
Check authorization status in Availity; standard medical necessity review turnaround is up to 14 days.

Documentation Required

HCPCS to NDC prompt behavior in Availity

When you enter an HCPCS code from the CGM list in Availity, the system will prompt selection of an unclassified DME product code and require entry of the 11-digit NDC in the new “CGM Product Code” field; users may search the NDC field by brand name.

Definitions

inv-08: Adjunctive CGM

DefinitionAdjunctive CGM identified in Availity HCPCS mapping as E2102 = Adjunctive CGM Receiver/monitor.

HCPCS mapping behaviorWhen an HCPCS code (including E2102) is entered, Availity prompts selection of an unclassified DME product code and requires entry of the 11-digit NDC in the 'CGM Product Code' field.

Preferred brands noteAvaility guidance lists preferred CGMs (FreeStyle Libre 2 and Dexcom) and indicates FreeStyle Libre 3 is not covered by CMS.

inv-09: Non-Adjunctive CGM

DefinitionNon-Adjunctive CGM identified in Availity HCPCS mapping as E2103 = Non-Adjunctive CGM Receiver/monitor and A4239 = Non-Adjunctive CGM Supplies.

HCPCS mapping behaviorWhen an HCPCS code (including E2103 or A4239) is entered, Availity prompts selection of an unclassified DME product code and requires entry of the 11-digit NDC in the 'CGM Product Code' field.