Eligibility requirements may vary widely from one payer to another, or even from one plan to another for any particular payer, so specific guidance is very difficult to obtain with certainty.

In general, referencing a treatment recommendation or standard from a reputable society can be helpful in seeking authorization. Focusing on the American Diabetes Association (ADA) Standards of Medical Care in Diabetes can be both instructive and helpful. The ADA Standards are updated regularly and published annually. The CGM-specific Standards can be found in the Technology section at this link.

The ADA also publishes an abridged version of the Standards specifically targeted to primary care. The 2023 update includes more CGM-specific guidance than ever before and can be found at this link. (After opening the link, scroll to section 7 on Diabetes Technology.)

Chart note examples: The following are examples of text that you can add to your chart notes for patients you feel would benefit from CGM. You can copy/paste, add to your EHR’s macro library (sometimes called smartphrases, dotphrases, or auto-text), and/or modify as needed. Some insurance companies require that the patient check fingerstick blood sugars three or more times daily, and an example reflecting this is included as well.

• This patient has a diagnosis of diabetes; is treated with insulin; requires frequent adjustment of the insulin treatment regimen based on glucose results; and has been personally seen to evaluate their diabetes treatment within the past 6 months.
• This patient has a diagnosis of diabetes; is testing a fingerstick glucose level 3 times a day and is using 3 or more daily administrations of insulin to manage their diabetes. This patient has required frequent adjustment of the insulin treatment regimen and would benefit from a CGM according to American Diabetes Association Standards of Medical Care in Diabetes-2024. I have seen and evaluated their diabetes treatment within the past 6 months.
• This patient is treated with 3 or more daily injections of insulin and would benefit from use of a continuous glucose monitor (CGM), as recommended in the American Diabetes Association Standards of Medical Care in Diabetes—2023 Abridged for Primary Care Providers (Clin Diabetes 2023;41(1):4-31): Recommendation 7.11 states that CGM should be offered for diabetes management in adults with diabetes on multiple daily injections (MDI) or CSII who are capable of using devices safely (either by themselves or with a caregiver)
• This patient is treated basal insulin and would benefit from use of a continuous glucose monitor (CGM), as recommended in the American Diabetes Association Standards of Medical Care in Diabetes—2022 Abridged for Primary Care Providers (Clin Diabetes 2023;40(1):4-31): Recommendation 7.12 states that CGM should be offered for diabetes management in adults with diabetes on basal insulin who are capable of using devices safely (either by themselves or with a caregiver).

A prescription or order will be required. Ordering through your EHR will make it easier to reorder in the future. Freestyle Libre and Dexcom require either a compatible smartphone or a reader.

• You can check compatible smart devices for the Dexcom here 
• You can check compatible smart devices for the Freestyle Libre here

• To order Dexcom if patient has a compatible smartphone:

Dexcom G7 sensors- dispense 3 boxes (9 sensors) per 90 days, change sensor every 10 days, 3 refills
OR
Dexcom G6 transmitter - dispense 1 per 90 days, 3 refills
Dexcom G6 sensors - dispense 3 boxes (9 sensors) per 90 days, change sensor every 10 days, 3 refills

• If patient does not have a compatible smartphone then also order:

  Dexcom G6 or G7 receiver (where G6 or G7 depends on which sensors you ordered above) - dispense 1, no refills

• Send an electronic prescription from your EHR to ASPN Pharmacies. ASPN will determine whether the patient’s particular plan covers Dexcom CGM through the pharmacy or DME benefit. ASPN will identity a participating pharmacy or DME supplier and forward the order information there for you. If you can’t find ASPN in your EHR’s list of pharmacies, ask your EHR administrator to add it.
  • ASPN Pharmacy phone: 888-489-0221, fax: 866-879-8150

   

• To order a Freestyle Libre if patient has a compatible smartphone: Freestyle Libre 2, Libre 2 plus, or Freestyle Libre 3 Sensors – change sensor every [X] days (X=14 for Libre 2, Libre 3; X=15 for Libre 2 plus), dispense 2 sensors (30-day supply), 11 refills
• If patient does NOT have a compatible smartphone: Freestyle Libre 2, Libre 2 plus, or Libre 3 Sensors- change sensor every [X] days (X=14 for Libre 2, Libre 3; X=15 for Libre 2 plus), dispense 2 sensors (30-day supply), 11 refills; AND Freestyle Libre 2 or 3 Reader - dispense 1 reader (reader life is approx. 3 years)
• Freestyle Libre 2, Libre 2 plus, and Libre 3 prescriptions are covered nearly exclusively through pharmacies under the pharmacy benefit.
• Most commercially insured patients pay $0 to $60 per month if covered; if copay will be >$75, have the patient call 844-330-5535 before picking up sensors from the pharmacy.

Order Guardian Connect transmitter and Guardian Sensors, dispense 3 sensors

• For Medtronic, visit their healthcare professional website for their most current resources: https://www.medtronic.com/us-en/healthcare-professionals/products/diabetes/continuous-glucose-monitoring-systems.html

Eversense requires that the transmitter be implanted; it is recommended that you seek preauthorization for the implantation procedure before ordering. To become an Eversense provider and to pursue information on ordering, visit https://www.ascensiadiabetes.com/eversense/become-a-provider/#get-started-form

Commercial payers generally do not require a Certificate of Medical Necessity or specific order form to prescribe to a pharmacy. However, chart notes and/or prior authorization may be requested. This is why it is important to include the applicable documentation (see examples above) in your chart notes. 

Dexcom:

Aaron West - Territory Business Manager
Email: aaron.west@dexcom.com
Can help with most Dexcom items, including Hello Dexcom samples.

Terra Thompson, RN, CDE - Clinical Account Manager
Email: terra.thompson@dexcom.com
Can help with all training and Clarity.

Kevin Stroud - District Business Manager
Email: Kstroud@dexcom.com

Can assist with urgent items.

Abbott Freestyle Libre:

Rick Burke

Phone: 408-569-5588

Email:rick.burke@abbott.com

• Professional CGM
• Sample of Personal CGM
• Self-pay for Personal CGM, with or without various coupons, copay reduction programs, and/or vouchers; over the counter CGMs are also a more affordable option that doesn't require a prescription
  

• Patient assistance and/or copay reduction programs
  • Dexcom patient assistance program: https://assistance.dexcom.com
  • Freestyle Libre: if copay will be >$75, have the patient call 844-330-5535 before picking up sensors from the pharmacy
  • Medtronic CGM patient assistance https://www.medtronicdiabetes.com/cgm-access-discount and Medtronic Assurance https://www.medtronicdiabetes.com/assurance
  • Eversense patient assistance: https://www.ascensiadiabetes.com/eversense/patient-assistance-program/
• Coupons are often available, for example through:
  • GoodRx
    • Dexcom G6 - https://www.goodrx.com/dexcom-g6
    • Dexcom G7 - https://www.goodrx.com/dexcom-g7 
    • FreeStyle Libre 2 - https://www.goodrx.com/freestyle-libre-2
    • FreeStyle Libre 3 -https://www.goodrx.com/freestyle-libre-3
  • SingleCare
    • FreeStyle Libre 2 - https://www.singlecare.com/prescription/freestyle-libre-2-sensor 
    • FreeStyle Libre 3 - https://www.singlecare.com/prescription/freestyle-libre-3-sensor 
    • Dexcom G6 - https://www.singlecare.com/prescription/dexcom-g6-sensor
    • Dexcom G7 - https://www.singlecare.com/prescription/dexcom-g7-sensor 
• Membership warehouses with pharmacies, like Costco and Sam’s Club, often offer the lowest prices, are usually open to non-members, and may have additional significant discounts for members.
• Free trials
  • MyFreeStyle offers a voucher for a free 14 day Libre 2 sensor through https://www.freestyle.abbott/us-en/myfreestyle.html
  • Medtronic has a 30-day trial program for their Guardian Connect system at https://www.medtronicdiabetes.com/guardian-connect-trial
• Samples
  • FreeStyle Libre 2 and/or Libre 3 samples can be requested from your local representative
  • Dexcom G7 sample samples can be requested from their provider website at https://provider.dexcom.com/prescribe-sample#block-contactus