As of April 1, 2019, customers managing diabetes will see expanded coverage options for therapeutic Continuous Glucose Monitor (CGM) sensors. This includes Dexcom G6® and Abbott FreeStyle Libre, the only therapeutic CGMs currently on the market. These CGMs are available with a prescription at in-network pharmacies.1
Coverage will continue under the medical benefit, but will expand to the pharmacy benefit as well. This means easier access to coverage for CGM sensor products. Although we will encourage customers and providers to fill CGM sensors under the pharmacy benefit with a prescription, we will continue to cover CGM sensors under the medical benefit for all clients/customers, whether or not they have integrated medical and pharmacy benefits.
Most clients and customers will experience improved savings when filling therapeutic CGMs under the pharmacy benefit instead of the medical benefit. In addition, through a program sponsored by the manufacturer of these CGMs, the transmitters and readers/receivers are offered at no additional cost at the pharmacy.2
For clients, the addition of coverage on the formulary for CGM sensors may help reduce overall health care spending on CGMs when medical and pharmacy spending is considered overall. Customer and client savings will vary by plan design and the specific CGM product.
Specific criteria determines if a CGM is appropriate for a customer
CGMs are not for everyone managing diabetes. Glucometers and finger sticks are still the most cost effective way to monitor glucose for those managing diabetes. A patient with type 2 diabetes, managed with oral medications, is not a likely CGM candidate. A patient who requires high dose insulin (Basal/long acting + rapid acting/mealtime insulin or an insulin pump) is a more appropriate candidate for a CGM. Prior authorization and quantity limits apply.
For customers with more challenging diabetes, therapeutic CGMs may be an appropriate mechanism for testing and managing blood sugar.3
Engagement-driven cost savings
Increased engagement in managing health conditions also helps generate medical cost savings for clients who connect their benefits with Cigna.
How therapeutic CGMs can improve care:
Cigna Pharmacy Management® will inform customers currently using a CGM (and their providers) of the expanded coverage now available under the pharmacy benefit.
Health benefit plans vary, but in general to be eligible for coverage a drug must be approved by the Food and Drug Administration (FDA), prescribed by a health care professional, purchased from a licensed pharmacy and medically necessary. Some plans require you to use an in-network pharmacy for prescriptions to be covered. Coverage is subject to any plan deductible, copayment and/or coinsurance requirements. Product availability may vary by location and plan type and is subject to change. All group health insurance policies and health benefit plans contain exclusions and limitations. For costs and details of coverage, contact a Cigna representative. Group medical and pharmacy plans are insured and/or administered by Cigna Health and Life Insurance Company or its affiliates. Policy forms: OK - HP-APP-1 et al., OR - HP-POL38 02-13, TN - HP-POL43/HC-CER1V1 et al. All pictures are used for illustrative purposes only. This website is not intended for residents of New Mexico.
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