Prescribers should follow the new patient prescription process. With expanded coverage for CGM, the Dexcom G6 Continuous, Glucose Monitoring (CGM) System is accessible for more of your. Anyone with PharmaCare Special Authority must get their Dexcom G6 supplies from a pharmacy. BC PharmaCare will not retroactively reimburse patients for benefits purchased before approval of a Special Authority request. 2021;27(6):505-537. Our Diabetes Management Incentive Program is designed to help educate and support members who take an active role in managing their diabetes. When completing the application, it may be necessary to answer No to the questions in section 2a/2b. To view a list of compatible smart devices, visit dexcom.com/compatibility. You may have pharmacy coverage for Dexcom through your insurance, which would allow you to get supplies at your local pharmacy. CGM devices covered by Medicare are defined in CMS Ruling 1682R as Once the Special Authority application has been submitted, approval may take 5-8 weeks. This process typically takes 2-3 business days. People living with diabetes can gain valuable insight about their glucose levels, rate, and direction of change, allowing them to proactively manage their diabetes. For patients currently using Dexcom G6 who turn 65 (becoming Medicare-eligible), how will they be transitioned to Dexcom G6 for Medicare? suspension of the applicants driving license, hospitalization or emergency room or EMS visit, glucagon administration, unconsciousness, or seizure. When will existing Medicare patients have access to Dexcom G6? At least one functional restriction that inhibits the use of blood glucose test strips (BGTS) (e.g., dexterity, mobility, dermatological problems). How can HCPs prescribe Dexcom G6 to their Medicare patients? NOTE:In addition to the above criteria, product specific dosage and/or frequency limits may apply in accordance with the U.S. Food and Drug Administration (FDA)-approved product prescribing information, national compendia, Centers for Medicare and Medicaid Services (CMS) and other peer reviewed resources or evidence-based guidelines. At the assessment appointment, a member of the DEP will confirm the patients eligibility and help them complete the rtCGM application form which will need to be sent to Dexcom. We comply with applicable . Dexcom Dexcom G5 Mobile CGM A9277 and K0553 Prior authorization is required. 0!o!eg[Z'K'xt[ Check your member profile to see if the Dexcom G6 CGM is a benefit under your Pacific Blue Cross plan. What if the patients claim is denied at the distributor? Please provide the following information, so we can determine your coverage: With this information, we will contact your insurance company and you to discuss your coverage options. % 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. All new and existing Pacific Blue Cross members must now apply for BC PharmaCare coverage of the Dexcom G6 CGM. 3 0 obj The estimated wait time between referral and an assessment appointment may take from 30 to 60 days. Please note you will need to be registered with Fair PharmaCare. In fact, Walgreens' Find Care marketplace introduced a program in 2019 in which interested people with diabetes can proactively request a prescription for the Dexcom G6. Discover how Dexcom G6 can empower your patients to make more informed for more information on the Patient Assistance Program. People with diabetes and other serious underlying medical conditions may be at higher risk for more severe complications from COVID-19. If a Medicare patient is denied coverage for Dexcom G6, it will be the distributors role to advise the patient or provider on the next steps for obtaining coverage. information and promotional communications related to Dexcom products. Anyone else experiencing this?? Please provide the following information, so we can determine your coverage: A completed Patient Information form And one of the following: A completed patient insurance form or A copy of the front and back of your insurance card With this information, we will contact your insurance company and you to discuss your coverage options. Dexcom will be phasing out its online store over the next several months. NOTE:Upgrade to or replacement of an existing CGM is considered not medically necessary when requested for convenience or simply to upgrade to a newer technology, when the current components remain functional, or when the current components remain under warranty. The information you provide will be sent securely and subject to the Dexcom respects 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. Full list of Medicare coverage criteria see the applicable coverage policy. Contract language, including definitions and specific inclusions/exclusions, as well as state and federal law, must be considered in determining eligibility for coverage. *28zVe +2a$ V Patients can expect their ADP assessment to take approximately 2-3 weeks after the submission of their application form. <> However, having it gives you a greater chance of developing type 2 diabetes later in life. Will PBC be making any system enhancements to better support members? If a current Dexcom G6 patient ages into Medicare eligibility (i.e., turns 65), they will be treated as a new patient. *You must be 18 or older on a Standard or Basic Option plan to earn this reward. %PDF-1.5 This process . CGM systems consist of a sensor, transmitter and receiver. *Medicare covers Dexcom G6 for insulin-requiring patients who meet the Medicare coverage criteria. The patient/family/caregiver agrees to comprehensive and age-appropriate diabetes education by an interdisciplinary diabetes healthcare team and commits to regular follow-up. Wednesday, Jul 21, 2021 The Dexcom G6 Continuous Glucose Monitoring (CGM) System is now covered through BC PharmaCare under Fair PharmaCare. 2017;167(6):365-374. If you are not affiliated with a DEP registered with the ADP, you will need to refer individuals who meet the ADP medical eligibility criteria to an ADP registered clinic. Diabetes Management Incentive Program. a Dexcom G6 receiver: $417.92 each (or $203.29 membership discount price) estimated total: $4,173 per year for lowest Costco membership, or $347 per month (not counting the optional Dexcom. 4 0 obj Whats the difference between the Dexcom G6 CGM and the Freestyle Libre 2 System? F 9Y|wr~;$PTAGC>:2CH!F&Qq& What documents must be provided to my insurance company? You can use these rewards to pay for qualified medical . ]Odx+q]3hzq- r !sDFFHpe~uF6\h6617ML'i/ii>p@F[0AGqn,LMu{aEJMf? Once approved, where do I purchase the Dexcom G6? Please follow the steps below to obtain BC PharmaCare coverage. Dexcom G6 Mobile CGM (Dexcom) was approved in 2018 and is indicated for the management of . 2023 Dexcom Canada, Co. All rights reserved. Receiver is required to be used along with smart device in order to receive Medicare benefits for CGM. The protection of your privacy will be governed by the privacy policy of that site. All rights reserved. CGM devices covered by Medicare are defined in CMS Ruling 1682R as #qHeoQ (!V"S6:bM&uTO>3}+Td9e=},)|7hTOq)s)H(b:J&vG_H C=V2YndWg 7 Beck RW, et al. 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. Continuous Glucose Monitoring (CGM) Systems (also known as Real-Time or interstitial) monitor, measure, and record glucose levels in interstitial fluid and produce data that show trends in glucose measurements. For the full list of Medicare coverage criteria, visit the Centers for Medicare and Medicaid Services website. Individual has type 1 diabetes and is receiving short- or rapid-acting insulin therapy; Individual has type 2 diabetes and is receiving short- or rapid- acting insulin therapy; Individual has gestational diabetes or is pregnant and a CGM is recommended by the provider; Updated policy to mirror pharmacy CGM policy, Individual has type 1 diabetes and is receiving short- or rapid-acting insulin therapy, Individual has type 2 diabetes and is receiving short- or rapid- acting insulin therapy, Individual has gestational diabetes or is pregnant and a CGM is recommended by the provider. The Diabetes Management Program by Livongo, Centers for Disease Control and Prevention (CDC), Work with a registered dietician to develop a healthy meal plan, Exercise at least 30 minutes a day, 5 days a week, Follow USDA ChooseMyPlate guidelinesfill half your plate with healthy fruits & vegetables, a quarter with protein & a quarter with whole grains, Take prescribed oral medication, insulin or a combination as directed by your doctor. Diabetes is more common than you may know. 2021: 65. I have been using G6 for almost a year and insurance has provided coverage up until now and I assume the policy changed because now they no longer do. Is the Dexcom G6 Medicare copayment more expensive than for that of other CGM brands? To ensure a successful transaction, please confirm your submitted First Name and Last Name match that associated wtih your NPI number. As such, we will be matching coverage criteria for the Dexcom G6 CGM for our Members. Has been seen in your clinic within the last 6 months, Uses an insulin pump or takes 3 daily administrations of insulin, Requires frequent adjustments to their insulin treatment regimen based on BGM or CGM testing results, For a complete description of Medicare coverage criteriaand additional information related to what should be included in the chart notes, please visit the, Centers for Medicare and Medicaid services website, 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 distributors below regarding their Dexcom G6 order. If approved, Dexcom will notify the patient to update them on their successful application and confirm the details of their first order. 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@? 7E^DPN)0>fe E+gM2^6xX3,o):,`5-ihS,3Ei6^.h,.#=DaSv/ee)w(($2HG\Oz~:P+S~XysQ b~\ vT(PAQ{ 4\' @e^NN(eU. ' iAGn u)ci` pi{QIZ`e[8q]smU9*2=C%8CJpx Type 1 diabetes is when your body doesnt make insulin, or makes very little insulin, and cannot move sugar into your cells for energy. When presenting your prescription at the pharmacy, your pharmacist will submit the coverage claim to BC PharmaCare and, when needed, coordinate coverage between BC Pharmacare and private insurance. Pacific Blue Cross will align coverage duration with PharmaCare. Time in range is a powerful supplement to A1C because it shows a more complete picture of changes in glucose levels. A small, reusable transmitter connects to the sensor and sends real-time readings wirelessly to a receiver, so users can view the information. Eligible members* who take steps to keep their A1c levels under control can earn up to $100 on their MyBlue Wellness Card by participating. permission to process your personal information to send you additional I was just denied coverage for dexcom. Over time, diabetes can increase your risk for serious health conditions, including heart disease, blindness, kidney failure and even amputations. 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. 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). Pacific Blue Cross will align with BC PharmaCares criteria for Dexcom G6 coverage. If you are a Dexcom User or Patient, please contact Dexcom When you have diabetes, your body doesnt produce enough insulin or the insulin that is produced is not able to move sugar in your cells, so it remains in the bloodstream. Seek medical advice and attention when appropriate, including for any medical emergency. This plan uses a Preferred Drug List (PDL). Programs and resources to help you better understand, manage and prevent diabetes. They simply complete a. Qualified individuals for the ADP funding will receive 100% coverage for their Dexcom G6. * The process is simple: Click the link below and fill out the form provided. <>/Metadata 327 0 R/ViewerPreferences 328 0 R>> EN Canada Language English franais Change Country. E~"*`xne@? Phone An adhesive patch holds the sensor in place so the sensor can measure glucose levels in the interstitial fluid. The PDL is a list showing the drugs that can be covered by the plan. Insulin, an important hormone made by the pancreas, allows sugar from food to turn into energy for your cells. Covered Diagnosis Codes Billed with Z79.4 for Procedure Codes: 0446T, 0447T, 0448T, 95249, 95250, 95251, A4238, A9276, A9277, A9278, E2102, G0308, G0309, K0553, K0554, S1034, S1035, S1036, S1037, Internal Medical Policy Committee 11-14-2019 Updated policy to mirror pharmacy CGM policy effective 1-1-2020 I know plans are different, but BCBS only covers Dexcom under DME and your endo has to include why you need it over regular glucose monitor (high A1C, hypo unaware, etc). Most people with type 1 diabetes on commercial health insurance are covered. 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. 1310 G Street, N.W. To add insurance information to your Dexcom online account, take the following steps: The Dexcom G6 Continuous Glucose Monitoring (CGM) System is covered by Medicare for type 1 or type 2 diabetic patients who meet the Medicare coverage criteria. Learn more here. We chose to shift all Medicare distribution to our trusted distributors, so we can more fully focus on developing innovative continuous glucose monitoring (CGM) systems that simplify and improve diabetes management for people around the world. Current patients may be eligible to receive ADP coverage for the sensors and transmitters used with their current rtCGM system if they meet all of the following: If your patient meets the criteria listed above, an ADP Application Form may be submitted on their behalf. To be eligible for coverage, individuals must meet the following Medical Eligibility Criteria: For your patients living with type 1 diabetes that meet the medical eligibility criteria stated above, they will need to be assessed and followed by healthcare professionals associated with a Diabetes Education Program (DEP) registered with the ADP. Replacement is not covered due to loss, negligence or improper use. Sorry, you need to enable JavaScript to visit this website. Also any experience with NC or TN Medicaid and their coverage of CGMs? endobj Everyones health insurance plan is different. All Dexcom G6 CGM purchases covered by BC PharmaCare need to be made at your pharmacy. Customer Service: 1-844-832-1810 Mon-Fri 9am-8pm EST. 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. A remote interstitial CGM (e.g., mySentry) is considered investigational/experimental and therefore, non-covered because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature. Likewise, medical policy, which addresses the issue(s) in any specific case, should be considered before utilizing medical opinion in adjudication. Click here to download a printable PDF copy of the ADP Application for Funding Real-Time Continuous Glucose Monitoring System (rtCGM). 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