CQI increases access to continuous glucose monitors for patients with Type 2 diabetes

Continuous glucose monitors, or CGMs, are powerful tools that can empower patients with Type 2 diabetes, and their primary care teams, to monitor and adjust lifestyle changes and medications in real-time. However, widespread adoption of monitor usage has been slow due to the high cost of CGMs and insurance coverage limitations. In fact, the Michigan Collaborative for Type 2 Diabetes, or MCT2D, found that nearly half of physicians report health insurance limitations have negatively impacted their ability to prescribe a CGM.

Therefore, MCT2D, a statewide collaborative quality initiative, made increased CGM access a priority focus. Recently, the MCT2D team successfully advocated with two major insurance companies, including Blue Cross Blue Shield of Michigan, to make CGMs easier to obtain and more affordable for patients.

United coverage expansion
Recently, United Healthcare collaborated with MCT2D to develop new guidelines that streamline CGM authorizations. Now, United commercial patients are eligible for CGMs under simplified criteria: having a diagnosis of Type 2 diabetes and a physician or practice participating in MCT2D.

“CGMs are a life-changing tool for many patients in managing Type 2 diabetes; I’ve seen that firsthand in my clinical work,” said Heidi Diez, clinical pharmacist and MCT2D program co-director. “I’m proud of the work that MCT2D is doing to bridge the gap between payer coverage and patient access to CGMs.”

The new guidelines are considered a significant milestone in MCT2D’s efforts and a victory for patients.

“When insurers and medical professionals are able to collaborate and work together for the good of the patient, positive changes can be made that help drive progress forward,” stated Jackie Rau, MCT2D program manager.

This change is effective immediately for practices that joined MCT2D in 2021. For practices that joined MCT2D in 2022, this change will go into effect in January 2023.

Blue Cross expands Medicaid coverage for CGM
Additionally, Blue Cross Complete, a Blue Cross Blue Shield of Michigan-managed Medicaid plan, worked with the MCT2D team on policy revisions to remove some glucose testing requirements and simplify documentation criteria for CGMs prescriptions. The result is increased access to CGMs for any Blue Cross Complete Medicaid patient in Michigan with Type 2 diabetes.

This expansion supports already existing coverage for Blue Cross’ commercial PPO members through the pharmacy benefit. In 2022, prior authorization was simplified by using claims lookback logic. Commercial PPO members with pharmacy coverage will have an automatic approval if they have at least one paid pharmacy claim for any diabetes medication within six months of the CGM request. The only medication exception to this automatic prior authorization is metformin because this can be used for indications other than Type 2 diabetes.

“We are excited to be able to offer CGMs to our members for them to learn how their diet and exercise choices affect their glucose control,” stated Marti Walsh, senior medical director at Blue Cross.  “There is evidence to support behavioral modification in patients based on this feedback.”

“Looking ahead, the collaborative will continue dialogue with partnering payers around expanding coverage as we continue to advocate for patient and practice access to CGMs,” said Diez.

Learn more about the changes: https://www.mct2d.org/news/celebrating-two-victories-in-expanding-cgm-coverage

MCT2D is funded by Blue Cross Blue Shield of Michigan as part of the BCBSM Value Partnerships program.

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