Prior authorization process for continuous glucose monitors (CGMs) and supplies
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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.
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.
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.
- 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.
Coding and Product Identifiers
| 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 |
Provider Submission and Dispensing Actions
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.
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.
Insulin pump with adjunctive CGM exception
If an insulin pump and an adjunctive CGM are being provided together, the initial authorization and initial CGM fill may be obtained through CareCentrix; subsequent CGM refills are supplied via participating in‑network retail or home delivery pharmacies without an additional authorization for the duration of the approved authorization.
- Use CareCentrix for the joint initial authorization and initial fill only when the insulin pump is provided at the same time as the adjunctive CGM.
- After the initial fill, refills come from in-network pharmacies and do not require a new authorization during the approved period.
Definitions
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