Continuous glucose monitor (CGM) insurance pre-approval (1436)
Key points below
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:
- Clinic gives insurance information to the DME company.
- The DME company may call you to confirm personal details.
- DME company sends a form to the clinic to fill out.
- Clinic sends the completed form to the DME company.
- DME company sends the form on to your insurance company.
- 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.