CurrentNeighborhood Health Plan of Rhode IslandPolicy 5282-H

Continuous Glucose Monitor (CGM) sensor quantity limits

This document defines product-specific monthly and multi-month quantity limits for continuous glucose monitoring (CGM) sensors for Neighborhood Health Plan of Rhode Island members and applies to the listed CGM products and strengths.

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 the per-product quantity limits and fill-duration rules (e.g., 25 days for a 30-day supply, 75 days for a 90-day supply) when processing CGM sensor fills.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3Dexcom G6 and G7 monthly limit

9Dexcom 3-month limit

2Freestyle Libre 4-week limit

5Enlite / Simplera monthly limit

75Eversense standard limit (days)

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 the per-product quantity limits and fill-duration rules (e.g., 25 days for a 30-day supply, 75 days for a 90-day supply) when processing CGM sensor fills.

SourceLink

On This Page

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Product-specific sensor quantity limits

Per-product quantity limits (examples extracted):

ALL of the following

Dexcom G6 — Month limit: 3 sensors (25 days).
Dexcom G6 — 3‑month limit: 9 sensors (75 days).

ALL of the following

Dexcom G7 — Month limit: 3 sensors (25 days).
Dexcom G7 — 3‑month limit: 9 sensors (75 days).

ALL of the following

Enlite — Month limit: 5 sensors (25 days).
Enlite — 3‑month limit: 15 sensors (75 days).

ALL of the following

Simplera Sensor — Month limit: 5 sensors (25 days).
Simplera Sensor — 3‑month limit: 15 sensors (75 days).

ALL of the following

Freestyle Libre 2 Plus Sensor — Month limit: 2 sensors (25 days).
Freestyle Libre 2 Plus Sensor — 3‑month limit: unspecified sensors (75 days).

ALL of the following

Freestyle Libre 3 Plus Sensor — Month limit: 2 sensors (25 days).
Freestyle Libre 3 Plus Sensor — 3‑month limit: unspecified sensors (75 days).

ALL of the following

Freestyle Libre 2 — 4‑week limit: 2 sensors (21 days).
Freestyle Libre 2 — 12‑week limit: 6 sensors (63 days).

ALL of the following

Freestyle Libre 3 — 4‑week limit: 2 sensors (21 days).
Freestyle Libre 3 — 12‑week limit: unspecified sensors (63 days).

ALL of the following

Freestyle Libre 14‑Day — 4‑week limit: 2 sensors (21 days).
Freestyle Libre 14‑Day — 12‑week limit: unspecified sensors (63 days).

ALL of the following

Guardian 3 — 4‑week limit: 5 sensors (21 days).
Guardian 3 — 12‑week limit: 15 sensors (63 days).

ALL of the following

Guardian 4 — 4‑week limit: 5 sensors (21 days).
Guardian 4 — 12‑week limit: 15 sensors (63 days).

ALL of the following

Eversense — Standard limit: 1 sensor (75 days).
Eversense E3 (XL) — Limit: 1 sensor (150 days).
Eversense 365 — Limit: 1 sensor (305 days).

Duration mapping applies to the per‑product limits above.

General duration mapping: 25 days used for 30‑day fill periods; 75 days for 90‑day; 21 days for 28‑day; 63 days for 84‑day; 150 days for 180‑day; 305 days for 365‑day — used to allow time for refill processing.

Products Referenced and Per-Product Thresholds

Products referenced (brand/generic sensors)mixed

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

Product-specific examples (explicit limits included in document)mixed

Dexcom G6	Month Limit = 3 sensors (25 days); 3 Month Limit = 9 sensors (75 days)
Dexcom G7	Month Limit = 3 sensors (25 days); 3 Month Limit = 9 sensors (75 days)
Enlite	Month Limit = 5 sensors (25 days); 3 Month Limit = 15 sensors (75 days)
Freestyle Libre 2 Plus Sensor	Month Limit = 2 sensors (25 days); 3 Month Limit = (unspecified number) sensors (75 days)
Freestyle Libre 3 Plus Sensor	Month Limit = 2 sensors (25 days); 3 Month Limit = (unspecified number) sensors (75 days)
Simplera Sensor	Month Limit = 5 sensors (25 days); 3 Month Limit = 15 sensors (75 days)

Fill-duration mapping (processing durations)mixed

30-day fill period	Duration = 25 days (allows time for refill processing)
90-day fill period	Duration = 75 days (allows time for refill processing)
28-day fill period	Duration = 21 days (allows time for refill processing)
84-day fill period	Duration = 63 days (allows time for refill processing)
180-day fill period	Duration = 150 days (allows time for refill processing)
365-day fill period	Duration = 305 days (allows time for refill processing)

Per-product quantity thresholds

Dexcom G6 / G73 sensors per month (25 days); 9 sensors per 3 months (75 days)

Enlite / Simplera5 sensors per month (25 days); 15 sensors per 3 months (75 days)

Freestyle Libre 2 / 3 (Plus)2 sensors per month (25 days); 3-month limit listed as 'sensors' (75 days) or 12-week = 6 sensors (63 days) for some variants

Freestyle Libre 14-Day2 sensors per 4 weeks (21 days); 12-week limit listed as 'sensors' (63 days)

Guardian 3 / 4Guardian 3: 5 sensors per 4 weeks (21 days); 15 sensors per 12 weeks (63 days). Guardian 4: 5 sensors per 4 weeks; 15 sensors per 12 weeks (63 days)

Eversense (standard / E3 XL / 365)Eversense: 1 sensor per 75 days; Eversense E3 (XL): 1 sensor per 150 days; Eversense 365: 1 sensor per 305 days

Quantity Limits and Fill-Duration Rules — Billing & Dispensing Guidance

Billing Rule

Quantity Limits and Fill-Duration Rules — Billing & Dispensing Guidance

Quantity limits apply per drug and strength; limits do not accumulate across products. Use the specified fill-duration conversions when determining allowable fills: a 25-day duration is used for a 30-day fill and 75 days for a 90-day fill to allow time for refill processing. For 28-day fills use 21 days (and 63 days for 84-day fills). For longer supplies use 75 days for 90-day, 150 days for 180-day, and 305 days for 365-day fill periods.

Dexcom G6: Month limit = 3 sensors (25 days); 3-month limit = 9 sensors (75 days).
Dexcom G7: Month limit = 3 sensors (25 days); 3-month limit = 9 sensors (75 days).
Enlite: Month limit = 5 sensors (25 days); 3-month limit = 15 sensors (75 days).
Freestyle Libre 2 Plus Sensor: Month limit = 2 sensors (25 days); 3-month limit = 6 sensors (75 days).
Freestyle Libre 3 Plus Sensor: Month limit = 2 sensors (25 days); 3-month limit = 6 sensors (75 days).
Simplera Sensor: Month limit = 5 sensors (25 days); 3-month limit = 15 sensors (75 days).

OpenPayer

Continuous Glucose Monitor (CGM) sensor quantity limits

Product-specific CGM Sensor Quantity Limits

Products Referenced and Per-Product Thresholds

Quantity Limits and Fill-Duration Rules — Billing & Dispensing Guidance

Fill-Period to Processing Duration Mapping