Beginning in 2024, continuous glucose monitors (CGMs) will only be covered through pharmacy benefits for fully funded commercial members

We’re making two changes to CGM coverage for fully funded commercial (group and individual) members in 2024.

1. Effective on January 1, 2024, most fully funded commercial members* will benefit from $0 CGMs and $0 CGM supplies through their pharmacy benefits 
2. Effective when a member’s plan renews in 2024, CGMs (excluding Medtronic) and related supplies will only be covered through pharmacy benefits (instead of through DME vendors and medical benefits)

*Coverage is after deductible for HDHP/HSA plans without the IRS Chronic Conditions (Rx) rider and plans where the deductible applies to pharmacy coverage. This includes small group Pre-ACA, transitional and grandfathered plans.

Why are we making these changes?

We’re making these changes to help ensure members with diabetes get the care they need without cost barriers. 

We also expect members to find the retail or mail-order pharmacy experience to be a more convenient process for them. Once their provider transfers their prescription, members can access pharmacies with same-day pickup. In addition, members using CGMs will already be filling insulin prescriptions through retail pharmacy or mail order.

Do these changes affect other diabetic supplies?

No. These changes do not affect any other diabetic supplies such as glucometers, test strips, lancets, pump supplies, etc.

What will the member impact be?

Impacted members will be notified of this change at least 60 days prior to renewal. We estimate that about 50% of diabetic members are already using pharmacy benefits for CGM coverage.

What do providers need to do?

For your patients with fully funded commercial Priority Health coverage, please begin sending all CGM prescriptions to pharmacies in 2024 as your patients’ fully funded commercial plans renew for the year.