Certain Blue Cross, BCN commercial members with diabetes are exempt from meeting clinical criteria for continuous glucose monitor product coverage

Blue Cross Blue Shield of Michigan and Blue Care Network commercial members with diabetes prescribed continuous glucose monitor products (for example, readers, sensors and transmitters) by physicians participating in either the Michigan Collaborative for Type 2 Diabetes Collaborative Quality Initiative or the Provider-Delivered Care Management program are no longer required to meet additional clinical criteria for coverage. This expansion of CGM product coverage ensures that Blue Cross and BCN commercial members with diabetes receive optimal care in alignment with the goals set forth by these clinical programs.

This criteria exception applies to prescription orders for CGM products submitted under the commercial pharmacy benefit and medical benefit.

Refer to the table below for additional information.

Frequently asked questions

What are CGM products, and how are these devices used?

CGM systems include a disposable sensor inserted under the user’s skin to continuously monitor blood glucose levels in real time, or intermittently. This sensor uses a transmitter, which may be part of the sensor itself or be reusable and attach to each new sensor, to send the blood glucose data to the user’s CGM reader or smartphone device. Examples of CGM systems include, but aren’t limited to, Dexcom® G6 and G7, and Abbott® Freestyle Libre systems.

What’s changing for commercial members prescribed CGM products under the pharmacy benefit?

Starting July 1, 2024, commercial members will qualify for automatic claim payment at the pharmacy counter (point of sale) without prior authorization if one of the following conditions are met: 

• Member prescribed CGM by a physician participating in the MCT2D program
• Member prescribed CGM by a physician participating in the PDCM program and has diagnosis code for diabetes (Type 1 or Type 2) on a prior medical claim

Commercial members will continue to qualify for automatic claim payment at the dispensing pharmacy without prior authorization if they have a prior pharmacy claim for insulin; however, insulin use isn’t required for automatic claim payment if either of the conditions above are met.

Commercial members who don’t qualify for CGM payment at the dispensing pharmacy and must request their health care provider to submit an electronic prior authorization to show that they fulfill clinical criteria for CGM coverage.

Visit bcbsm.com/druginfo for a complete list of CGM products covered under the commercial pharmacy benefit. Refer to current commercial coverage requirements for CGM here.

What’s changing for commercial members prescribed CGM under the medical benefit?

Northwood, Inc.** is an independent company that manages both prior authorizations and the supplier network for durable medical equipment billable through the medical benefit, including CGM products, for certain commercial members.

Commercial members with diabetes within the Northwood network will continue to require prior authorization approval for CGM product coverage; however, those prescribed CGM by a MCT2D- or PDCM-participating physician aren’t required to meet additional clinical criteria for coverage.

The following provides additional guidance:

• Before Sept. 1, 2024, physicians must attest to their participation in either the MCT2D or PDCM program by including a comment on the CGM prescription to exempt commercial members from fulfilling clinical criteria for prior authorization approval under the medical benefit.
• Starting Sept. 1, 2024, Blue Cross and BCN commercial members will have their prior authorizations automatically approved by Northwood under the medical benefit if they are prescribed CGM by a physician participating in either the MCT2D or PDCM program.

What is the definition of a “MCT2D-” or “PDCM-participating physician”?

• A MCT2D-participating physician is a primary care physician provider or specialist currently enrolled in the MCT2D CQI and eligible to receive value-based reimbursement.
• A PDCM-participating physician is a doctor who rendered PDCM claims to 1% of their attributed member population on two different dates of service.

When are the lists of MCT2D- and PDCM-participating physicians updated?

• The MCT2D-participating physician list is updated on a biannual basis:
• New participating primary care physicians will be added to the MCT2D-participating physician list in September 2024, based on their value-based reimbursement eligibility status at the end of August 2024.  
• New participating specialist physicians will be added to the MCT2D-participating physician list in March 2025, based on their value-based reimbursement eligibility status at the end of February 2025.
• The PDCM-participating physician list is updated once annually:
• New participating physicians will be added to the 2024 PDCM physician list if they rendered PDCM claims to 1% of their attributed population on two different dates of service based on 2022 calendar year claims.
• Physicians who achieved the 1% PDCM claim threshold who are eligible for the CGM criteria exception will be flagged on the annual September PDCM value-based reimbursement reports that physician organizations receive from Blue Cross.

Physicians newly participating in either MCT2D or PDCM must wait up to 45 days for their CGM prescriptions to qualify for automatic payment at the retail pharmacy. During this interim period, these new participating physicians must submit an electronic prior authorization, or ePA, to attest to their participation in one of these programs to exempt the member from meeting clinical criteria for CGM coverage.

Physicians newly participating in either MCT2D or PDCM must also wait up to 45 days for their CGM prescriptions to qualify for automatic prior authorization approval from Northwood. During this interim period, these new participating physicians must attest to their participation in one of these programs on the CGM order submitted to Northwood by the DME supplier.

How should health care providers submit prior authorization requests for CGM products for Blue Cross and BCN commercial members?

For commercial Blue Cross and BCN members with pharmacy benefit coverage:

Health care professionals should submit electronic prior authorization requests for CGM products through an online prior authorization platform (for example, CoverMyMeds® portal).**

For commercial Blue Cross and BCN members without pharmacy benefit coverage:

Members in the Northwood network require prior authorization approval for CGM product coverage. The DME supplier (the company that dispenses the CGM product) will submit the prior authorization request to Northwood on behalf of the prescribing health care provider.

Exclusions to the Northwood network may apply. For more information, see the Durable medical equipment, prosthetics and orthotics, and medical and diabetes supplies management program: Frequently asked questions for DMEPOS providers document.

How to members’ eligibility and benefits

It’s essential that providers check each member’s eligibility and benefits before ordering CGM products. Certain members may not have pharmacy benefits through Blue Cross or BCN. Additionally, certain members may be exempt from requiring prior authorization for CGM products based on their benefit type.

Health care professionals can access Blue Cross and BCN provider manuals available in the Availity® provider portal for guidance on how to verify member eligibility and benefits and instructions on how to submit prior authorization requests for CGM products.

To access the Blue Cross and BCN provider manuals:

1. Log in to Availity at availity.com.**
2. Click on Payer Spaces on the menu bar and then click on the BCBSM and BCN logo.
3. Click on the Resources tab.
4. Click on Secure Provider Resources (Blue Cross and BCN).
5. Under the Publications drop-down menu, select Manuals.

Questions?

If you have questions, email Allison Olmsted at aolmsted@bcbsm.com.

*Commercial members prescribed CGM by a physician participating in either the MCT2D- or PDCM program are exempt from fulfilling these clinical criteria for coverage. Criteria outlined above is current as of July 1, 2024, and may be subject to change.

**Blue Cross Blue Shield of Michigan and Blue Care Network do not own or control these websites.

Availity^® is an independent company that contracts with Blue Cross Blue Shield of Michigan and Blue Care Network to offer provider portal and electronic data interchange services.

Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association.