CurrentNeighborhood Health Plan of Rhode IslandPolicy 5282-H

Continuous Glucose Monitor (CGM) sensor quantity limits

This document defines initial quantity limits and refill durations for specified continuous glucose monitor sensors and applies to the payer's referenced products and members covered under those products.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyContinuous Glucose Monitor (CGM) sensor quantity limits

Policy CodePolicy 5282-H

Change TypeNo material change

Effective Date

Next Review Date

Key ActionApply specified initial quantity limits and refill durations per product when processing sensor supply claims.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3Dexcom G6 1-month limit

9Dexcom G6 3-month limit

2Freestyle Libre 4-week

1Eversense standard

5Enlite/Guardian 1-month

Initial Quantity Limits and Coverage Criteria

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Initial quantity limits

Initial quantity limits by product and corresponding duration windows:

ALL of the following

Dexcom G6: 1 month — 3 sensors (duration used: 25 days)
Dexcom G6: 3 month — 9 sensors (duration used: 75 days)

ALL of the following

Dexcom G7: 1 month — 3 sensors (duration used: 25 days)
Dexcom G7: 3 month — 9 sensors (duration used: 75 days)

ALL of the following

Enlite: 1 month — 5 sensors (duration used: 25 days)
Enlite: 3 month — 15 sensors (duration used: 75 days)

ALL of the following

Simplera: 1 month — 5 sensors (duration used: 25 days)
Simplera: 3 month — 15 sensors (duration used: 75 days)

ALL of the following

Freestyle Libre 2 Plus Sensor: 1 month — 2 sensors (duration used: 25 days)
Freestyle Libre 2 Plus Sensor: 3 month — 6 sensors (duration used: 75 days)

ALL of the following

Freestyle Libre 2: 4 week — 2 sensors (duration used: 21 days)
Freestyle Libre 2: 12 week — 6 sensors (duration used: 63 days)

ALL of the following

Freestyle Libre 3: 4 week — 2 sensors (duration used: 21 days)
Freestyle Libre 3: 12 week — 6 sensors (duration used: 63 days)

ALL of the following

Freestyle Libre 14-Day: 4 week — 2 sensors (duration used: 21 days)
Freestyle Libre 14-Day: 12 week — 6 sensors (duration used: 63 days)

ALL of the following

Guardian 3: 4 week — 5 sensors (duration used: 21 days)
Guardian 3: 12 week — 15 sensors (duration used: 63 days)

ALL of the following

Guardian 4: 4 week — 5 sensors (duration used: 21 days)
Guardian 4: 12 week — 15 sensors (duration used: 63 days)

ALL of the following

Eversense: standard — 1 sensor (duration used: 75 days)

ALL of the following

Eversense E3 (XL): standard — 1 sensor (duration used: 150 days)

ALL of the following

Eversense 365: standard — 1 sensor (duration used: 305 days)

Provider Billing Rules and Refill Guidance

Billing Rule

Quantity limits and refill durations (per product)

Initial quantity limits are defined per product with specific refill-duration windows used to calculate allowable fills. Providers must follow these product-specific limits when submitting claims and scheduling refills.

Dexcom G6/G7: 1 month = 3 sensors / 25 days; 3 month = 9 sensors / 75 days.
Enlite: 1 month = 5 sensors / 25 days; 3 month = 15 sensors / 75 days.
Freestyle Libre 2 Plus & Freestyle Libre 3 Plus: 1 month = 2 sensors / 25 days; 3 month = 6 sensors / 75 days.
Simplera: 1 month = 5 sensors / 25 days; 3 month = 15 sensors / 75 days.
Duration mapping used for refill processing: 25 days for 30-day fills, 75 days for 90-day fills, 21 days for 28-day fills, 63 days for 84-day fills, 150 days for 180-day fills, 305 days for 365-day fills.
Limits do not accumulate together; patient is allowed the maximum limit for each drug and strength.

Definitions and Limit Rules

Limit accumulation

DefinitionLimits do not accumulate together; patient is allowed the maximum limit for each drug and strength.

Practical effectWhen multiple limits are listed for the same product (e.g., 1-month and 3-month), they are applied independently and patients may receive the maximum allowed for each listed period.

Billing implicationClaims adjudication should not combine quantities across different limit windows to exceed the maximum specified for a given drug/strength.

Duration mapping for refill processing

30-day (1-month) fill processing window25 days — used to allow time for refill processing.

90-day (3-month) fill processing window75 days — used to allow time for refill processing.

28-day (4-week) fill processing window21 days — used to allow time for refill processing.

84-day (12-week) fill processing window63 days — used to allow time for refill processing.

180-day fill processing window150 days — used to allow time for refill processing.

365-day fill processing window305 days — used to allow time for refill processing.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyContinuous Glucose Monitor (CGM) sensor quantity limits

Policy CodePolicy 5282-H

Change TypeNo material change

Effective Date

Next Review Date

Key ActionApply specified initial quantity limits and refill durations per product when processing sensor supply claims.

SourceLink

On This Page

Dexcom (all products)
Eversense (all products)
Freestyle Libre (all products)
Guardian (all products)
Simplera (all products)

OpenPayer

Continuous Glucose Monitor (CGM) sensor quantity limits

Initial Quantity Limits and Coverage Criteria

Products Referenced and Fill-Period Durations

Provider Billing Rules and Refill Guidance

Definitions and Limit Rules