Prior authorization policy for preferred continuous glucose monitors (CGMs) and supplies
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BlueMedicare HMO and PPO Medicare Advantage patients may obtain preferred CGMs (Dexcom and FreeStyle Libre) and supplies without prior authorization; non-preferred/adjunctive CGMs still require authorization. Applies to Part B coverage channels noted in the document.
Preferred continuous glucose monitors (Dexcom and FreeStyle Libre) and supplies for BlueMedicare HMO and PPO patients no longer require prior authorization beginning January 1, 2024.
Prior authorization remains required for non-preferred adjunctive CGMs (e.g., Guardian) and related supplies.
Coverage Criteria for Continuous Glucose Monitors
Preferred continuous glucose monitors (CGMs) for BlueMedicare HMO and PPO beneficiaries are the Dexcom and FreeStyle Libre product families. When the patient meets CMS eligibility (treated with insulin or meets CMS hypoglycemia event thresholds) and the prescriber sends a prescription for the CGM and maintenance supplies to an in-network retail or home delivery pharmacy, these preferred CGMs and their supplies do not require prior authorization. Preferred products may be obtained from local in-network retail pharmacies or via home delivery (mail-order) pharmacy per the payer's distribution options.
Non-preferred CGMs, described as adjunctive CGMs (examples include Guardian devices), remain subject to the payer's prior authorization process and are not in the preferred/no-prior-authorization category. Once a non-preferred adjunctive CGM is authorized, the prescription and maintenance supplies should be sent to the member's chosen in-network retail or home delivery pharmacy.
This policy does not present a separate list of clinical scenarios labeled explicitly as “not medically necessary.” Instead, the document distinguishes products by administrative coverage pathway: specified preferred CGMs (Dexcom and FreeStyle Libre) are afforded an administrative exception to prior authorization, while other CGMs not on that preferred list are managed through the payer’s prior authorization requirements and submission workflows.
As a practical matter, absence of a ‘not medically necessary’ label means clinical eligibility follows CMS criteria for Part B CGM coverage; administrative access (no prior authorization vs. prior authorization required) is determined by whether the device is on the payer’s preferred list.
Coding and Product Identifiers
| 08627003011 | DEXCOM G4 PLATINUM PEDIATRIC RECEIVER KIT |
| 08627003021 | DEXCOM G4 PLATINUM 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 |
| 08627002031 | DEXCOM G4 PLATINUM RECEIVER KIT |
| 08627005104 | DEXCOM G5 MOBILEIG4 PLATINUM SENSOR KIT |
| 63000041338 | GUARDIAN 4 GLUCOSE SENSOR |
| 63000051968 | GUARDIAN 4 GLUCOSE SENSOR |
| 63000044515 | GUARDIAN 4 TRANSMITTER KIT |
| 63000044516 | GUARDIAN 4 TRANSMITTER KIT |
| 43169095568 | GUARDIAN LINK 3 TRANSMITTER KIT |
| 76300000805 | ENLITE GLUCOSE SENSOR |
| 76300010001 | GUARDIAN REAL-TIME REPLACEMENT MONITOR |
Provider Actions and Prior Authorization Workflow
Prior authorization requirement
Preferred CGMs (Dexcom and FreeStyle Libre) and their maintenance supplies do NOT require prior authorization for BlueMedicare HMO and PPO patients effective 2024-01-01. Prescribers should send the CGM and supplies prescription to any in‑network retail pharmacy or home delivery (mail‑order) pharmacy of the patient’s choice. CMS coverage and documentation expectations (initial and six‑monthly follow‑up visits documenting adherence) still apply.
- Applies to Dexcom and FreeStyle Libre preferred products and supplies
- Obtainable from in‑network retail or home delivery pharmacy
- CMS requires initial qualification and follow‑up every six months
Non‑preferred CGM prior authorization requirement
Requests for non‑preferred adjunctive CGMs (for example, Guardian products) require prior authorization and will continue to be submitted via Availity per the enhanced process implemented April 2023. Prior authorization may be denied if the authorization criteria are not met.
- Non‑preferred = adjunctive CGMs (e.g., Guardian)
- Submission via Availity — follow Availity instructions posted in the prior bulletin
- Prior authorization required before dispensing; may be denied if criteria unmet
Insulin pump with adjunctive CGM documentation flow
When a non‑preferred adjunctive CGM is being provided together with an insulin pump, the initial authorization and first supply may be obtained through CareCentrix at the time the pump is provided. Subsequent CGM supply refills are dispensed through the patient’s participating in‑network retail or home delivery pharmacy and do NOT require a separate authorization during the approved authorization period.
- Initial authorization and initial fill for adjunctive CGM bundled with insulin pump: CareCentrix pathway
- Subsequent refills: in‑network retail or home delivery pharmacy — no additional authorization required during authorization period
- Exception: follow local CareCentrix instructions for pump + CGM provision
Step therapy / submission pathway
Step therapy / submission pathway: non‑preferred adjunctive CGM prior authorization requests should be submitted through Availity using the streamlined prior authorization process. Providers must follow the Availity instructions for required documentation and clinical criteria; detailed submission guidance is available in the prior bulletin referenced by Florida Blue.
- Submit non‑preferred adjunctive CGM (e.g., Guardian) PA requests via Availity
- Include supporting clinical documentation per Availity/Florida Blue requirements
- See prior bulletin for step‑by‑step submission instructions
Prescription and follow-up documentation
Prescription and follow‑up documentation: prescribers must send CGM and maintenance supply prescriptions to an in‑network retail or home delivery pharmacy. For CMS‑covered beneficiaries, document initial medical necessity and perform in‑person or CMS‑approved telehealth visits every six months to confirm adherence to the CGM regimen and diabetes treatment plan.
- Send prescriptions to in‑network retail or home delivery pharmacy
- Document initial qualification and keep six‑month follow‑up visit notes to support continued coverage
- Follow CMS documentation standards for hypoglycemia events and insulin treatment status
Definitions and Eligibility
Background
Continuous glucose monitors (CGMs) are covered under Medicare Part B when CMS clinical eligibility is met. CMS-defined eligibility generally includes patients treated with insulin or patients who meet specified hypoglycemia event thresholds; providers must also perform follow-up visits to document adherence and the diabetes treatment plan at intervals noted in the policy.
Florida Blue’s operational change effective January 1, 2024, makes selected CGM products and supplies more administratively accessible for BlueMedicare HMO and PPO members: preferred CGMs (Dexcom and FreeStyle Libre) and their supplies can be obtained without prior authorization from an in-network retail or home delivery pharmacy. However, non-preferred adjunctive CGMs (e.g., Guardian) continue to require prior authorization under the payer’s established processes. When an adjunctive CGM is initially provided with an insulin pump, authorization may be obtained through the payer’s designated channel (for example, CareCentrix) with subsequent refills supplied through in-network pharmacies during the approved authorization period.
Revision History
Preferred continuous glucose monitors (Dexcom and FreeStyle Libre) and related supplies for BlueMedicare HMO and PPO patients no longer require prior authorization effective January 1, 2024; these may be obtained from in-network retail or home delivery pharmacies.
Prior authorization remains required for non-preferred adjunctive CGMs (for example, Guardian devices) and related supplies; these continue to be managed under the payer's existing authorization processes.
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