CurrentHighmark Blueshield NenyPolicy N/A

Diabetes Management Program (Virtual Diabetes Care) - Coverage Criteria

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Defines Highmark's virtual diabetes care programs (Verily Me for Type 1 and Onduo for Type 2), who is eligible, services offered, and exclusions for members covered under specified Highmark products.

Policy Summary

PayerHighmark Blueshield Neny

PolicyDiabetes Management Program (Virtual Diabetes Care) - Coverage Criteria

Policy CodePolicy N/A

Change TypeMaterial update — new T1D program and clarified CGM provision for T2D

Effective DateJan 1, 2024

Next Review DateN/A

Key ActionEnroll eligible patients through the Highmark member portal and provide CGM to Type 2 members who meet listed clinical criteria.

SourceLink

POLICY UPDATE CHANGES

A Type 1 diabetes (T1D) program on the Verily Me platform is new for 2024 and includes a 'bring your own device' option.

Members meeting certain clinical criteria will be provided with a continuous glucose monitor (CGM) upon enrollment in the Type 2 program.

2Platforms

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CurrentHighmark Blueshield NenyPolicy N/A

Diabetes Management Program (Virtual Diabetes Care) - Coverage Criteria

Customize your policy alerts

Sign up for all Highmark Blueshield Neny policy alerts

Know when Highmark Blueshield Neny releases new policies or updates existing guidance.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Defines Highmark's virtual diabetes care programs (Verily Me for Type 1 and Onduo for Type 2), who is eligible, services offered, and exclusions for members covered under specified Highmark products.

Policy Summary

PayerHighmark Blueshield Neny

PolicyDiabetes Management Program (Virtual Diabetes Care) - Coverage Criteria

Policy CodePolicy N/A

Change TypeMaterial update — new T1D program and clarified CGM provision for T2D

Effective DateJan 1, 2024

Next Review DateN/A

Key ActionEnroll eligible patients through the Highmark member portal and provide CGM to Type 2 members who meet listed clinical criteria.

SourceLink

POLICY UPDATE CHANGES

A Type 1 diabetes (T1D) program on the Verily Me platform is new for 2024 and includes a 'bring your own device' option.

Members meeting certain clinical criteria will be provided with a continuous glucose monitor (CGM) upon enrollment in the Type 2 program.

2Platforms

Coverage Criteria

Program enrollment and services

Covered when ALL of the following are met for program enrollment

Enrollment general eligibility: Member has historical claims indicating Type 1 or Type 2 diabetes and primary insurance coverage through Highmark under a fully‑insured commercial, ACA, ASO (opt‑in), or Medicare Advantage plan (T1D specifics); Type 2 eligibility references minimum ages.

T1D requires Highmark coverage as noted; TZD age thresholds are listed separately.

Services included: Access to virtual clinics, remote monitoring, tools, coaching, certified diabetes care and education specialists (CDCES), health coaches, dietitian, and endocrinologists via the program.

Program platforms differ by diabetes type (Verily Me for T1D; Onduo for T2D).

CGM provision for T2D: Type 2 members who meet certain clinic criteria (for example: Emergency Room encounter; A1C threshold noted in source; currently on insulin; or had no recent provider visit) will be provided a continuous glucose monitor (CGM) upon enrollment.

Source lists example clinical criteria; exact A1C numeric threshold in the document appears unclear ('AIC 28' in source).

Enrollment in the Diabetes Management Program is excluded for certain members and clinical situations. Excluded members include BlueCard members and those with Alzheimer’s disease or dementia. The policy also excludes members with the following conditions: cystic fibrosis, congestive heart failure (grade C or D), chronic kidney disease (stage 4, stage 5, and ESRD), gestational diabetes, members in hospice or otherwise institutionalized, organ or bone marrow transplant recipients, liver failure and/or cirrhosis, pregnancy, and members receiving radiation therapy.

This policy does not present separate “not medically necessary” (NMN) rationales; instead it provides an explicit list of enrollment exclusions. Where a condition or membership status is listed under Exclusions, that circumstance is not eligible for program enrollment rather than being described via an NMN statement.

Coding and Thresholds

Age and clinical thresholds

Minimum age for Type 2 (TZD)> 13 years (document lists Ages > 13)

Alternate age threshold listed> 18 years (document also lists Ages > 18)

Clinical criteria affecting program eligibility/CGM provisionMembers who meet certain clinic criteria (e.g., Emergency Room encounter; A1C threshold noted as 'AIC 28' in source; are on insulin; or had no provider visit) are identified for additional services.

Provider Actions and Operational Notes

Prior Authorization

Enrollment and CGM provision

Members enroll in the Diabetes Management program via the Highmark member portal. For Type 2 members who meet clinical criteria — for example, recent Emergency Department encounter, A1C above program threshold, current insulin use, or lack of a recent provider visit — a continuous glucose monitor (CGM) will be provided upon enrollment.

Enrollment via Highmark member portal
Type 2 members meeting clinical criteria (ED encounter, A1C threshold, insulin use, or no recent provider visit) eligible for CGM provision upon enrollment

Step Therapy

Step therapy

No step therapy requirements are specified in this document.

Background

The Diabetes Management Program is a virtual health solution that delivers remote monitoring, virtual clinics, personalized coaching, and access to diabetes specialists to support management of Type 1 and Type 2 diabetes between office visits. Services include connections to CDCES clinicians, health coaches, dietitians, and endocrinologists, digital tools for self-management, and program-specific platforms (Verily Me for Type 1 and Onduo for Type 2). The program’s goals are improved medication adherence, better clinical outcomes, and reduced emergency department utilization.

Definitions

Diabetes Management Program

Program descriptionA virtual health solution that provides virtual clinics, remote monitoring, tools, coaching, and access to CDCES, health coaches, dietitians, and endocrinologists.

Platforms by diabetes typeVerily Me platform for Type 1 (T1D); Onduo 'classic' platform for Type 2 (T2D).

Primary services offeredTools, coaching, clinical support and remote monitoring to help manage diabetes between office visits.

Continuous Glucose Monitor (CGM) provision

CGM provision policyType 2 members who meet certain clinic criteria (e.g., Emergency Room encounter; A1C threshold noted in source; are on insulin; or had no provider visit) will be provided a continuous glucose monitor (CGM) upon enrollment.

Eligibility linkage