Getting a CGM for Type 2 Diabetes with Private Insurance
The benefits of using a continuous glucose monitor (CGM) as a person with any type of diabetes are significant and well-known. However, there are still many unnecessary barriers and obstacles to getting a CGM for people with type 2 diabetes (T2D).
Here, we’ll look at why CGM access is important for people with T2D, common qualifications if you have private insurance
Why do people with type 2 diabetes need a CGM?
The more blood sugar data you have, the more you can live safely day-to-day with diabetes and prevent the development or progression of diabetes complications.
While A1c testing offers a glimpse into how your blood sugars have been doing over the course of the previous three months, it can’t help you in your day-to-day, hour-by-hour diabetes management.
An A1c result cannot tell you what times of day your blood sugars are frequently high or frequently low to help you make adjustments in your regimen and medications—with support from your healthcare team.
Blood sugar checks using test-strips, a meter and a finger-prick are also lacking because it doesn’t tell you the direction of your blood sugar. Like an A1c result, it also cannot alert you to rising or falling levels while you are sleeping, walking your dog, or while you are driving.
A CGM, on the other hand, can tell you:
- Real-time blood sugar levels every five minutes
- Your average blood sugar
- Your time-in-range, above range, below range
- If your blood sugar is rapidly falling or rising
- If you fall low while you are asleep otherwise occupied
- When and how often you are high or low
- …and share this data in real-time with a family member
- …and share this data in reports with your healthcare team
A CGM is simply today’s standard of care for the most informed—and safest—life with any type of diabetes. As diabetes technology has evolved, access to that technology ought to evolve, too, making it accessible to anyone living with any type of diabetes.
Who qualifies for a CGM on private insurance?
The short answer: it can vary wildly from one insurance company to another—or the plan you choose within an insurance company. You should speak directly with your insurance company to determine what you qualify for.
While some insurance companies may require a person with T2D to be on at least one or two types of insulin, other companies might cover the costs of a CGM if you simply enroll in their diabetes coaching program, regardless of your medications.
Calling the customer service number for the manufacturers of the CGM will fight for you and help you with the process.
“I have so many patients with type 2 diabetes who cannot get a CGM, and they would really benefit from using a CGM,” says Vivian Ayuk, Pharm D., and CDCES. Ayuk founded the Sorogi Health and Wellness Center which specializes in working with people with diabetes.
“I’ve seen a huge improvement in A1c levels of patients who are only on basal insulin, and able to get a CGM,” says Ayuk. “Why is your diabetes medication regimen still a barrier and a requirement? It shouldn’t be. I look forward to the day people with diabetes can get what they truly need to manage their blood sugars.”
The cost, even with insurance, is also a challenge. The most affordable CGM technology still often comes with a copay cost of about $75 per month.
But Ayuk is hopeful that access to CGM technology will gradually improve.
“A lot of them are beginning to relax the rules, because more research is showing the benefits—especially the long-term benefits,” adds Ayuk. “The cost of a CGM is a lot less than the cost of a severe hypoglycemic event that sends you to the emergency room.”
The cost of a CGM is easily outweighed by the benefits it could offer through preventing diabetes complications years down the road.
“Unfortunately, many private insurers are still following very outdated rules on who qualifies for a CGM with type 2 diabetes.”
Ayuk says her patients who use a CGM are often overwhelmed—but only at first—by the amount of information they gain from the technology. Quickly, they become grateful for the changes it leads to in how they manage diabetes day-to-day.
“The information they’re getting around nutrition, physical activity, medication dosages…it’s like turning a light on in the room,” says Ayuk. “They get so much more insight as to how their blood sugars react to everything. Then they use that information to make changes. It’s a game-changer and it’s empowering. They feel like they are in control, and they don’t have to worry as much.”
The impact a CGM has on the value of appointments with her patients is significant, too.
“Appointments are far much more engaging, because they have so much more to share,” adds Ayuk. “They can say, ‘Here’s what this did to my blood sugar and here’s what happened on this day when I did this.’ And we have all this additional information to make adjustments to their diabetes regimen.”
What to ask when you call your insurance provider
“Depending on your commercial coverage it may be considered ‘durable medical equipment’ or a pharmacy expense,” explains Christel Marchand Aprigliano, chief advocacy officer at Beyond Type 1.
“The Freestyle Libre is usually covered by the pharmacy part of your insurance coverage, while Dexcom usually goes through as DME—but not always. You should also ask them what your out-of-pocket expenses will be, especially if you have a high-deductible plan.”
Before you ask your prescriber to write the prescription, Marchand Aprigliano also urges you to call your insurance provider and confirm if you’re eligible for coverage and whether it would fall under your DME or pharmacy plan, because it affects how your doctor starts the “prior authorization” process.
“You should absolutely also contact the manufacturer of the CGM because they will have someone to walk you through the process,” explains Marchand Aprigliano. “They will work with your prescriber to help you get coverage.”
Loopholes to using CGM technology if you don’t qualify
“You can request a ‘professional CGM’ through your prescriber,” explains Marchand Aprigliano. “Your prescriber puts the sensor on you in the office, but it’s usually blinded—which means you can’t actually see your blood sugar data in real-time.”
Generally, you can wear a professional CGM for 7 to 14 days. Then your prescriber will download the data and review it to potentially make changes in your diabetes management regimen. Those changes might include putting you on an “intensive insulin regimen” which would then fully qualify you for a CGM and reimbursement through Medicare.
You can also call the manufacturer of the CGM and ask what discount programs they offer to people who can get a prescription but cannot get insurance coverage. These programs can bring the out-of-pocket price down to $75 per month, for example, which is similar to the copay with insurance coverage.
Does your healthcare team understand the value of CGM technology?
“The biggest barrier is getting approval from your insurance company,” adds Ayuk. “But some patients may struggle with getting their healthcare team to even prescribe it.”
The process of requesting “prior authorization” from your insurance company for something like a CGM can be time-consuming for your prescriber. If they don’t understand the value of a CGM for T2D, they may discourage you from pursuing it, and recommend using test-strips and a glucose meter instead.
“I worry there are a lot of patients who might actually have coverage for a CGM, but their doctor hasn’t recommended it because they don’t understand what this technology can do,” says Ayuk. “If that conversation is not being had with their doctor, the patient might think it’s not for them or that they don’t need it.”
Ayuk adds that she knows healthcare providers are overwhelmed in today’s current healthcare system, and wishes a discussion about CGM technology would become a routine part of diabetes care.
“We are considering having reminder cards for our providers at the Sorogi Health and Wellness Center,” says Ayuk. “Potentially pamphlets about CGMs to help start the conversation.”
“The first thing I hear back from patients using a CGM is, ‘Wow, it feels great to not prick my finger every day!’ It’s such a relief for them,” says Ayuk.
“Technology is a tool that could really help you better manage. Everyone who could benefit should have access to it. Having insulin be a factor that determines who should and who should not is unfortunate.”
Educational content related to CGMs for type 2 diabetes is made possible with support from Dexcom. Beyond Type 2 maintains full editorial control of all content published on our platforms.