In The News
CGM has advanced diabetes management, with demonstrated improvements in glycemic management, reduction of hypoglycemia-related resource utilization, and enhanced member engagement and self-management. While this technology was initially prescribed predominantly for those living with type 1 diabetes (T1D), the mounting body of evidence and expert recommendations have led to more widespread use in insulin-treated T2D, necessitating the implementation of evidence-based benefit design policies by health plans. During this working group meeting, leading payer and managed care decision makers reviewed recent findings and shared their insights on best practices for CGM coverage and reimbursement, including alignment with clinical practice guidelines, availability under the pharmacy benefit, and automated adjudication at the point of sale.
 Jim Kenney, RPh, MBA (Moderator)Founder and President JTKenney, LLC | Clinical Pharmacist, Healthcare and Family Services Bureau of Professional and Ancillary Services University of Illinois at Chicago |
 Thomas Grace, MDMedical Director Blanchard Valley Diabetes Center |  Estay Greene, PharmD, MBAVice President of Pharmacy Zing Health |
 Eric Long, PharmD, MBADisease Management Pharmacist Beacon Health System |  Scott McClelland, PharmDVice President, Commercial and Specialty Pharmacy Programs Florida Blue |
 Josh Moore, PharmDDirector of Pharmacy MO HealthNet Division Missouri Department of Social Services |  Diane E. Morgan, PharmDDirector, Specialty Pharmacy Government Programs Pharmacy UnitedHealthcare  |
 Heather Mullins, PMPSenior Clinical Program Manager UnitedHealthcare |  Susan Wescott, RPh, MBAExecutive Lead, Clinical Services, Alluma, LLC Senior Director of Pharmacy, Managed Care, Mayo Clinic |
In support of this working group, a survey of managed care professionals was conducted. Click here to download the results.
This article reports key findings from recent randomized, observational, and retrospective studies investigating use of CGM in type 2 diabetes (T2D) individuals treated with basal insulin only and/or noninsulin therapies. Data from 29 studies were reviewed and analyzed. Both randomized and prospective/retrospective studies have demonstrated significant glycemic improvement, reductions in diabetes-related events and hospitalization rates, and cost benefits of persistent CGM use by individuals with T2D who are treated with basal insulin only, basal plus noninsulin medications, and noninsulin medications without insulin. In 23 (79%) of the 29 studies reviewed, investigators reported associations between CGM and improvements in HbA1c and/or key CGM metrics. These findings, alone, provide strong evidence that supports providing access to this technology to those with T2D who are less intensively treated. The narrative presents an evidence-based rationale for expanded access to CGM within the T2D basal insulin only and/or noninsulin treated population. Recent clinical guidelines from the American Diabetes Association and American Association of Clinical Endocrinology now endorse CGM use in individuals treated with nonintensive insulin regimens. Access in the basal insulin only population has expanded since the start of this project. CGM should be made readily available to all individuals with diabetes who are able to use this technology safely and effectively.
Learn MoreThis infographic highlights the value of CGM for positively impacting diabetes care quality, with special consideration given to underserved demographics of patients based on race/ethnicity and age. The piece links to the 2023 AMCP symposium moderated by Dr. Gary Puckrein, President and Chief Executive Officer of the National Minority Quality Forum, where diabetes care disparities and quality were also brought into focus. Also linked is an expert interview with Diana Isaacs, PharmD, with insights on disparities in diabetes care and quality considerations. Guidance is offered on improving CGM access as a means for meeting recent HEDIS quality measures tied to reducing emergency department and hospital use. Using findings from Blue Cross Blue Shield North Carolina as a case study, the infographic serves as a call-to-action for payers to remove manual prior authorizations for CGM under the pharmacy benefit.
The Centers for Medicare and Medicaid Services (CMS) expanded CGM access to beneficiaries on basal-only insulin or those with a history of level two or three hypoglycemia. Although the Local Coverage Determination (LCD) was originally anticipated to be implemented in July, CMS expanded access to CGM on April 16, 2023. This new coverage policy is aligned with consensus guidelines from the ADA and AACE, which recommend CGM for all patients on insulin at the outset of diagnosis. The new LCD, which was proposed in 2022, also removes the term “daily” as a descriptor for insulin to account for potential FDA approval of weekly insulins in the future.
Learn MoreEffective January 1, 2023, UnitedHealthcare (UHC) is making selected continuous glucose monitoring (CGM) devices and sensors available to Medicare Advantage members at the pharmacy point-of-sale (POS). The systems affected by this change in policy include the Dexcom G6 as well as the FreeStyle Libre 2 and 14-day versions. CGMs were previously only available to UHC Medicare Advantage members through national durable medical equipment (DME) vendors. While availability through DME vendors will remain in place, the plan sought to improve access to CGMs for members by expanding to the pharmacy POS. Managed care decision makers should take note of this change in policy as an example of how national payers are leveraging the pharmacy channel as a means of enhancing coverage and member access to beneficial diabetes technologies.
Learn MoreDexcom G7 is now cleared in the U.S. for people with all Types of diabetes ages two years and older, giving more people than ever access to a powerfully simple diabetes management solution. The next-generation real-time continuous glucose monitoring system demonstrates comparable accuracy to previous versions while offering a smaller sensor and enhanced ease-of-use features.
Learn MoreLilly’s new Tempo personalized diabetes management platform features a reusable medical device that attaches to prefilled, disposable insulin pens and sends dose-related data to a compatible app. Patients attach the Tempo Smart Button to the Tempo Pen to send insulin-dose information to TempoSmart. Capturing the data facilitates medication reminders, personalized education resources, and feedback on blood glucose levels, realized through integration with compatible technologies, including real-time continuous glucose monitoring (RT-CGM) via the Dexcom G6. Labeled a “diabetes ecosystem” solution, the fully integrated combination of devices, drugs, and technology offers an opportunity to adapt to each patient’s unique needs in diabetes management while providing value to both physician and payer stakeholders at the same time.
Learn MoreAccording to the 2022 American Association of Clinical Endocrinology (AACE) Clinical Practice Guideline, CGM is recommended for all persons with T1D, regardless of insulin delivery system, to improve A1C levels and to reduce the risk for hypoglycemia and DKA. The updated guideline likewise recommends CGM for those with T2D who are treated with insulin therapy, or who have high risk for hypoglycemia and/or who have hypoglycemia unawareness. These recommendations are Grade A—indicating the highest strength made by the AACE—and are supported by the best evidence level available, based on data from randomized controlled trials. Managed care and payer professionals should take note of this latest guideline as part of the growing body of consensus recommendations supporting the coverage of CGM in a broader population of members with diabetes.
Blonde L, et al. American Association of Clinical Endocrinology Clinical Practice Guideline: Developing a Diabetes Mellitus Comprehensive Care Plan-2022 Update. Endocr Pract. 2022;28(10):923-1049.