Continuous Glucose Monitor (CGM) Insurance Pre-Approval

Continuous Glucose Monitor (CGM) Insurance Pre-Approval

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How can I get a CGM?

First, we need to find out if it is a prescription benefit or a medical benefit. 

  • Call you insurance company. You can find the number on the back of your child’s insurance card. Ask these questions:
    • “Which CGMs are covered with my insurance plan?”
    • “Is this covered under medical benefits or pharmacy benefits?”
    • If medical, “which DME company is this insurance contracted with?”
  • If you need help calling your insurance company, let the diabetes clinic know.

If the CGM is covered as a pharmacy benefit

  • You will be called about the cost.
  • A prescription can be sent to the Skywalk Pharmacy or your preferred pharmacy.
  • Some insurances also need a prior authorization. This means that the insurance company will look at your child’s medical history to see if they will pay for part of the CGM.
  • This part of the process can take 1 to 2 weeks.

If it is not covered as a pharmacy benefit, or if the pharmacy benefit costs too much:

  • A durable medical equipment (DME) supplier (like Edgepark, Byram, or Solara) will work with your insurance. The process is:
  1. Clinic gives insurance information to the DME company.
  2. The DME company may call you to confirm personal details.  
  3. DME company sends a form to the clinic to fill out.
  4. Clinic sends the completed form to the DME company.
  5. DME company sends the form on to your insurance company.
  6. Your insurance company decides if they will pay for the CGM.
  • Paperwork for the DME may not be able to be completed until staff have enough data to fill it out.
  • If insurance approves the CGM, you will get it and other supplies from the DME company. Insurance does not always approve the CGM.

Important information about CGM

  • Plan for 4 to 8 weeks from the start of the process to your child getting the CGM.
  • If you haven’t heard from the pharmacy or DME company, call the company for updates- not the clinic. They will have the most up-to-date information.
  • Insurance companies may need to see records of blood sugar testing at least 4 times a day for a certain amount of time. 

When your child gets the device

  • Call the clinic to schedule a nurse visit to place the first CGM   Or
  • Start your CGM at home. The clinic can send you online resources to find the information you need for a home start. 

ALERT

Call your child’s doctor, nurse, or clinic if you have any questions or concerns or if your child has special health care needs that were not covered by this information.