CurrentHighmark DelawarePolicy N/A

Diabetes Management Program (Vendor-supported virtual diabetes care)

Describes a vendor-supported diabetes management program offered to eligible Highmark members, including included services, clinical outcomes, eligibility (inclusion/exclusion), enrollment/referral pathways, and FAQs. It is a member program description rather than a formal coverage/benefit determination or billing policy.

Policy Summary

PayerHighmark Delaware

PolicyDiabetes Management Program (Vendor-supported virtual diabetes care)

Policy CodePolicy N/A

Change TypeInformational

Effective Date

Next Review Date

Key ActionProviders may receive patient Encounter Summaries after each virtual visit; patients can print or send summaries via eFax to facilitate information sharing and collaborative care.

POLICY UPDATE CHANGES

No material clinical/coverage changes

1.6%Avg HbA1C reduction

4.4 mmHgAvg systolic BP reduction

16.6 mg/dlAvg total cholesterol reduction

9 lbAvg weight loss

Program summary and key outcomes

This is an informational description of a vendor-supported diabetes management program offered by Onduo to eligible Highmark members. The program provides digital monitoring, access to a virtual clinic (including nutritionists, endocrinologists, and Certified Diabetes Care and Education Specialists), personalized care leads and coaching, and home testing supplies such as blood glucose monitors, test strips, lancets, and at-home A1C testing.

The program supports management of both Type 1 (T1D) and Type 2 diabetes (T2D) between office visits to help improve clinical outcomes and reduce emergency department utilization. This summary is informational and not a coverage determination.

Program eligibility and exclusions

Program Eligibility and Exclusions

Members must meet ALL of the following inclusion criteria and must not meet any exclusion criteria:

Top-level eligibility

Enrollment requirement: Member is enrolled in a Highmark Affordable Care Act, Medicare Advantage, or Commercial Plan
Diabetes type and age criteria (ONE of)
- Type 1 Diabetes (T1D): Ages ≥ 13
- Type 2 Diabetes (T2D): Ages ≥ 18
Medicaid/Wholecare exclusion: Member is not enrolled in a Medicaid/Wholecare Plan
Listed as exclusion elsewhere; program not available to Medicaid/Wholecare enrollees
Absence of listed clinical exclusions (NONE of the following)
- Pregnancy
- Cirrhosis
- Chronic kidney disease (CKD) stage 4 or 5
- Prior organ transplant
- Cystic fibrosis
- Active cancer
- Alzheimer's disease

Placeholder

Actions, referral & documentation for providers

Documentation Required

Share Encounter Summaries

Providers may receive patient Encounter Summaries after each virtual visit; patients can print or send summaries via eFax to facilitate information sharing and collaborative care.

Encounter Summaries via eFax or print

Billing Rule

Program Supplies Provided at No Cost to Patient

Blood glucose monitor, test strips, lancets, and at-home A1C testing are provided to participating members at no cost. Note: copays and deductibles may still apply for provider appointments or medications.

Blood glucose monitor
Test strips
Lancets
At-home A1C testing

Prior Authorization

Enrollment / Referral Pathways

Providers can refer members through the Availity Essentials portal; members can self-enroll via the My Highmark app or member website.

Provider referral: Availity Essentials
Member self-enroll: My Highmark app / member website

Supporting evidence

Evidence includes the JMIR publication: Majithia AR et al. J Med Internet Res 2020;22(8):e21778. Reported study details: n=55 with 60 days intermittent CGM wear; an asterisk notes n=43 in a subgroup or related measure.

Frequently asked questions

Q: Why should I use this?

A: High quality care providers, improved clinical outcomes, and free blood sugar and A1C testing supplies for eligible members.

Q: When should my patient enroll vs. seeing a Specialist?

A: Patients should see their Specialist to manage diabetes and issues requiring physician care; the program supports management between visits.

Q: How will I receive information regarding the progress of my patient using the solution?

A: Patients can share their Encounter Summary after each virtual visit by printing it or sending it via eFax to the provider.