If you are on 3 or more injections a day and you are testing your blood sugars at least 3-to 4 times a day you will qualify by Medicare criteria. The PDL is a list showing the drugs that can be covered by the plan. View the Preferred Drug List (PDL) Once approved, where do I purchase the Dexcom G6? 3 0 obj Check out the changes and updates to our plan in 2023. Send the patients certificate of medical necessity (CMN) and chart notes to the distributor, Let your patient know that they will be contacted by the distributor regarding their Dexcom G6 order, 92% of Dexcom Medicare patients report that they are somewhat to extremely satisfied with product ease of use.4, The Medicare copay for Dexcom G6 is the same price as other CGM brands.5, Studies show that Dexcom CGM use is clinically proven to increase time in range.7-9. <> T2/2000/Tresiba,Ozempic,Metformin/Dex G6. g9=_ONozKsifm7k =dk!?j jy`-=_}-#|b{i>r*j_rcD(:|\6zs@v8%?-n/kRV[+QTr!9Ih$$%$T3~ o FBTUs]BcYWr0$|]8*rp>in|XKRseNaC4=>d3)id@SQxgXV1R!'yrT&NhaYFXxl(_7 P9yUg=Q\}?&~Ve;d=h_WvERd*s>=Gc(sFlx%l,#*_u1 t(`QP2.]r+X#L1#CO>`?Z .ulNm/ve4L0 e.DGQ!J.89Gqr o}v]>r@? The Freestyle Libre 2 is not a BC PharmaCare benefit. A patient must call their plan to confirm that the distributor is in their network. Cookie Notice Your prescriber can complete the Special Authority Request. https://www.dexcom.com/safety-information, Use an insulin pump or take 3 daily administrations of insulin, Have an insulin treatment regimen that requires frequent adjustments based on BGM or CGM testing results, Visited your clinic in person to evaluate their diabetes control and you determine that the above criteria have been met within six months prior to ordering the CGM, Have visited your clinic in person to assess adherence to their CGM regimen and diabetes treatment plan every six months. Individual private insurance plans may differ and are subject to change. All rights reserved. Step 1: Ask your doctor to e-prescribe your Dexcom CGM supplies to your local pharmacy and to confirm coverage with your pharmacist. https://www.dexcom.com/en-CA/public-coverage, https://www.ontario.ca/page/insulin-pumps-and-diabetes-supplies#section-3, Owing to their developmental stage or a previously diagnosed cognitive or physical impairment, Applicant is, unable to recognize or communicate symptoms of hypoglycemia; or. In such circumstances, it is recommended to complete a rtCGM Funding Exception Request Form (click to view sample) and submit it along with the ADP Application Form. Click here to download a PDF summary of the Ontario ADP coverage information. Also, many Medicare beneficiaries have secondary insurance that covers their copayment. Dexcom, headquartered in San Diego, is dedicated to helping people better manage their diabetes by developing and marketing continuous glucose monitoring (CGM) products and tools for adult and pediatric patients. You will be going to a new website, operated on behalf of the Blue Cross and Blue Shield Service Benefit Plan by a third party. · Heres everything you need to know about it. The easiest indication for Dexcom G6 or Dexcom G7 coverage by insurance is insulin use. Since A1C is a three-month average, it doesnt give insight into potentially dangerous high and low glucose variations. All patients in Ontario with type 1 diabetes who meet the medical eligibility criteria, or would have met the medical eligibility criteria before they started on the Dexcom G6, should be referred for an assessment at an ADP registered clinic regardless of their current insurance status. 2019;21(3):128-132. Personal CGM systems can exist as a stand-alone system or integrated with an insulin pump. I have used dexcom for over 10 years, dozens of different policies and never denied! You can use these rewards to pay for qualified medical . Medicare covers therapeutic CGM devices under the DME benefit. Studies have shown that CGM systems may help reduce A1C levels and reduce hypoglycemia. How can HCPs prescribe Dexcom G6 to their Medicare patients? Pacific Blue Cross will align with BC PharmaCares criteria for Dexcom G6 coverage. Initially users will be covered for one year. All new and existing Pacific Blue Cross members must now apply for BC PharmaCare coverage of the Dexcom G6 CGM. Dexcom, Dexcom Follow, Dexcom CLARITY, and Dexcom Share are registered trademarks of Dexcom, Inc. in the U.S., and may be registered in other countries. Learn more here. Does Pacific Blue Cross provide CGM coverage? * Dexcom data on file (commercial insurance plans for T1 and T2 patients taking insulin). Glucose results are used by the individual to closely monitor their glucose levels to help them to better self-manage their diabetes. Please note: Information provided with the sample request is validated against Provider's license information. To view a list of compatible smart devices, visit dexcom.com/compatibility. For more information on BC PharmaCare coverage and the Special Authority and Fair PharmaCare programs please see the following links: How to apply for Special Authority from BC PharmaCare. Please use this form to assist in identifying members who meet Blue Cross Blue Shield of Massachusetts' . x\moFna?JpRZ; h@?$-QZIT(%K IvvUO~ |s~x3{`w|Y(X6dM~xwP I'&"k$$?c[@K$C RX 8jdA$("m|]^|jRkX"A&A+T8 6m3 W D}hYFu9HXhsc%Xx~GVcmLId*p(Za4P}y/O[=AAH`3>B!\$j\3H1 -$uZETTA\{v7G5SHV2.&DA ADP coverage for Dexcom G6 rtCGM is available for adults and children (2 years and older) living with type 1 diabetes, who are residents of Ontario and have a valid Ontario health card. Click here to download a printable PDF copy of the ADP Application for Funding Real-Time Continuous Glucose Monitoring System (rtCGM). While there is no cure for diabetes, it can be managed. For patients currently using Dexcom G6 who turn 65 (becoming Medicare-eligible), how will they be transitioned to Dexcom G6 for Medicare? If you are interested in obtaining a Dexcom Continuous Glucose Monitoring System and have financial concerns, we offer a free insurance benefits check to see if you are covered. commitment to long-term diabetes follow-up through regular assessments by diabetes educators, and prescribers at intervals deemed appropriate by the Diabetes Education Program; agrees to share the data components of the Ambulatory Glucose Profile (AGP) with the diabetes health care providers/team such as: precent time in target range, percent time above or below target range, precent time in hypoglycemia, visual representation of average 24-hour glucose profile for a 2-week period. 4 0 obj Internal Medical Policy Committee 3-16-2020 removed invalid diagnosis codes, Internal Medical Policy Committee 7-22-2020 removed Eversense CGM experimental/investigational statement, updated description, added additional diagnosis codes: E11.10, E11.11, E11.8 and E11.9 and added "Billed with Z79.4" to covered diagnosis codes section, Internal Medical Policy Committee 7-22-2021 Added diagnosis code Z96.41, Internal Medical Policy Committee 3-23-2022 Added new codes A4238 and E2102 to the policy effective 4-1-2022, Internal Medical Policy Committee 7-21-2022 Added new codes, G0308 and G0309, to the policy effective 7-1-2022, Fargo (Headquarters) endobj #1 preferred CGM system This change applies only to the Dexcom G6 CGM. If they do not have a compatible receiver, they will get a new Dexcom G6 receiver. If rejected, Dexcom will notify the patient of their unsuccessful application and discuss their options moving forward. please fill out the form and a representative will contact you. Dexcom CARE team - 1-877-339-2664 Qualified individuals for the ADP funding will receive 100% coverage for their Dexcom G6. Dexcom G6 Mobile CGM (Dexcom) was approved in 2018 and is indicated for the management of . Also, many Medicare beneficiaries have secondary insurance that covers their copayment. ( OVtN How long will I be covered for the Dexcom G6? Sign up to receive our monthly email newsletter, tips for healthy living, and important updates. A CGM system may be considered medically necessary whenONEof the following criteria are met: All other uses for CGM systems are considered experimental/investigational and therefore, non-covered because their safety and/or effectiveness cannot be established by the review of the published peer-reviewed literature. Members residing outside of BC should have their Prescriber or Diabetes Specialist complete the Dexcom G6 CGM request form and return to us for review. Diabetes is more common than you may know. Eligible members* can earn up to $100 on their MyBlue Wellness Card by participating in the program. &y/Brb4L xDAs?3t%Nufg|{CRt-Jm6lN(+/.}NX[oP4i*V }"WI"+i\mQb}d*W.i}H ?;E%}p}o]>H7 {"/:|Y }=l~Tx~dEW%[A+ |)Z9D%SE WW@Y\j7+nH! a physician or nurse practitioner, registered with the ADP-registered DEP as a prescriber, confirms that prior to starting real time continuous glucose monitoring, they met the device-specific Medical Eligibility Criteria. Individuals who meet the following criteria will be eligible for BC PharmaCare coverage: An occupation where hypoglycemia presents a significant safety risk (e.g., pilots, air traffic controllers, commercial drivers). %PDF-1.5 Medicare covers therapeutic CGM devices under the DME benefit. Covered Diagnosis Codes Billed with Z79.4 for Procedure Codes: 0446T, 0447T, 0448T, 95249, 95250, 95251, A4238, A4239, A9276, A9277, A9278, E2102, E2103, S1034, S1035, S1036, S1037, Internal Medical Policy Committee 11-14-2019 Revision -Effective January 01, 2020, Internal Medical Policy Committee 3-16-2020 coding update, Internal Medical Policy Committee 7-22-2020 Revision, Internal Medical Policy Committee 7-22-2021 Coding update, Internal Medical Policy Committee 11-23-2021 Updated description, non-invasive CGM and remote CGM language, Internal Medical Policy Committee 3-23-2022 Coding update-Effective April 01, 2022, Internal Medical Policy Committee 7-21-2022 Coding update -Effective July 01, 2022, Internal Medical Policy Committee 11-29-2022 Coding update -Effective January 01, 2023. Pacific Blue Cross supports this change, which will provide British Columbians living with diabetes more options for diabetes management. Type 2 diabetes is when you have some insulin, but your body does not use or make insulin properly to move sugar into your cells for energy. Sugar in the blood comes from the foods that we eat. Blue Cross & Blue Shield of Rhode Island (BCBSRI) follows the medical necessity criteria from the Centers . Prescribers should follow the new patient prescription process. 2021: 65. Dexcom G5 Mobile App Android Devices Only, Dexcom G5 Mobile App Apple Devices Only. The Dexcom G6 costs approximately $3,600 annually and the Libre 2 Flash is approximately $2,600 annually. No, the Dexcom G6 Medicare copayment is the same price as other popular CGM brands. Continuous Glucose Monitoring (CGM) is a method to track glucose levels throughout the day and night. Dexcom G6 is also covered by both the Ontario Disability Support Program (ODSP) and Assistance for Children with Severe Disabilities Program (ACSD) as a Mandatory Special Necessities Benefit. 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