Who’s eligible for a Continuous Glucose Monitor (CGM) and how you can get one has changed a lot in the last year.
If you’ve been denied a CGM in the past, or if you’re just looking for a smoother, less time-consuming way to get your diabetes supplies, now is the time to take action.
Let me walk you through the different options and how I get my CGM (and other diabetes supplies).
This post is sponsored by US MED.
Who’s eligible for a CGM and what has changed recently?
I’ve been living with type 1 diabetes since 1997 and started using the Dexcom Continuous Glucose Monitor about 6 years ago, and I think it has been one of the most powerful improvements to my diabetes management.
The CGM allows me to see my blood sugar readings 24/7 on my phone or a receiver and alerts me if my blood sugars start to go too high or low so I can be proactive in my care.
But not everyone living with diabetes in the US has access to CGM, often because their (private or government) insurance won’t cover it. But the good news is that a lot has happened and it has now become easier to be approved for a CGM.
CGM coverage if you have private insurance
Most private insurance plans cover CGM for people living with diabetes, but you’ll have to check your insurance benefits to see if that’s the case with your plan, which brands it covers, and at what price.
Plan coverage can change from year to year, so if you have been denied coverage in the past, it’s worth checking up on your plan benefit annually or choosing a plan that covers CGM during open enrollment (which is usually November through January).
Most people will have some sort of copayment when using a private insurance plan. If you, for example, have a 20% co-pay, that means that you’ll pay 20% of the price your insurance plan has negotiated with the CGM manufacturer.
If you use a distributor for your medical supplies, such as US MED that I’m using, they will contact your insurance company for you, before you even sign up with them, to find out if you’re covered and what your co-pay is.
CGM coverage if you have Medicare
Over 62 million people are enrolled in Medicare in the US and about 30% of those people live with diabetes.
There are several criteria a person has to fulfill to be eligible for a CGM through Medicare, but a redundant barrier to coverage was removed recently which should make it easier to get coverage for CGM.
This barrier was removed at the beginning of July 18, 2021, where Medicare eliminated the four-time-daily fingerstick testing requirement for CGM coverage.
So if you have been denied coverage in the past because you didn’t manually check your blood sugar four times daily, now is the time to re-apply for CGM coverage.
To be eligible for coverage through Medicare, you still have to fulfill these criteria:
- You must live with diabetes
- You have to manage your diabetes with multiple (three or more) daily insulin injections (MDI) or an insulin pump
- You must require frequent insulin self-adjustment based on the CGM or finger sticks
- You must have seen a medical professional in person within 6 months prior to ordering the CGM
- You must see the prescribing medical professional in person every 6 months following the initial prescription of the CGM
Your out-of-pocket cost for your CGM will depend on what your Medicare benefit plan looks like. But instead of spending hours on the phone trying to get through to a Medicare representative, another option is to just reach out to US MED and have them run the numbers for you.
It’s super easy, just go to USMED.com and you can contact them electronically or give them a call.
CGM coverage if you have Medicaid
Although it’s great that most private insurance plans and Medicare now covers CGM for more people living with insulin-dependent diabetes, unfortunately, Medicaid coverage is a bit more sporadic.
Medicaid is the single largest source of health coverage in the United States, providing health insurance to more than 80 million Americans.
Medicaid overage differs greatly from state to state which makes it harder to figure out if you’re covered, and unfortunately many states do not cover CGMs in their Medicaid programs.
Anyone living with diabetes under the age of 21 on any Medicaid program qualifies for a CGM, but for anyone older than 21, it becomes a bit more complicated.
20 states (21 in 2022) currently have fairly comprehensive Medicaid coverage of CGM for people living with any type of diabetes, whereas 22 states only have coverage for people living with type 1 diabetes and 7 states have no published coverage.
Who qualifies also differs from state to state with most states requiring prior authorization from a doctor, but you’ll have to check with your state’s Medicaid program for specific eligibility criteria, or reach out to a distributor such as US MED.
Dexcom doesn’t deliver directly to customers anymore, now what?
If you decide to get a CGM, whether it’s through your insurance or you decide to go ahead and pay for it yourself, you have different options when it comes to delivery.
Neither of the most frequently used CGM brands, being Dexcom or Freestyle Libre, sell directly to the user. You used to be able to get your CGM directly from Dexcom here in the US, but they discontinued that completely in May 2021.
That means that you have to use a distributor or get your CGM from your local pharmacy (if they carry it). I usually get my diabetes supplies and insulin from my local pharmacy but they don’t carry Dexcom so I get my CGM from US MED, which is a distributor.
US MED is an accredited nationwide distributor of CGMs, diabetes testing supplies, insulin pumps, and more. With the change in insurance qualifications criteria, they accept 100s of private insurance providers and Medicare. They also get great reviews on Google and Facebook!
What I like about US MED is that it’s so easy to use and very convenient. You simply go to the US MED website and either fill out the online form or call them for a free benefits check. You are then assigned a personal customer service rep, a feature I don’t know of any other diabetes supplies companies that have, and that rep takes care of you from there.
Once you decide to get your supplies (which for me is my Dexcom CGM, but again, they also deliver FreeStyle Libre CGM, test strips, and other medical devices), they’ll provide free shipping of your 90-day supply directly to your home with UPS.
When it’s time to reorder, you can do it easily over text message, the online portal, or over the phone. It only takes seconds!
They’ll even give you automatic reorder reminders like text, email, or calls so always remember to reorder your diabetes supplies.
Super easy, and you can always check up on your account by logging into the patient portal. The portal is helpful because it keeps all of your records in one place. You track shipping and see all of your previous orders in a secure online environment.
It also saves you time from having to call in if your personal info has changed, like address, insurance coverage, or physician’s name.
So if you’re considering a CGM or are looking for a great solution to have your 90-day supplies delivered directly to your door, I suggest you give US MED a call to learn if you qualify for a CGM, what your out-of-pocket costs will be, and to set up your next delivery.
Kari Williams says
Any tips on getting a CGM covered for a teen with hypoglycemia? They say it’s not diabetes, just hypoglycemia, as A1C and C-Peptide are normal. She stays in the 40s-50s and insurance won’t approve CGM because she doesn’t take insulin.
Christel Oerum says
I don’t know if any insurance will grant that. But a way to explore it is to work with her doctor and go through the appeal process together. First, she’ll need a prior authorization, and if that’s denied you can appeal it. You might be able to fight it on your own but in my experience, you need the prescribing doctor to help with the appeals
Have you had your doctor check for antibodies? My A1C and c-peptide were normal for years but I would get really bad gestational diabetes. Finally my A1C started creeping up and I went to an endocrinologist who wanted to treat me as a type 2 who didn’t “make a lot of insulin” I had my PCP run antibody tests and I was tens time what I should be for one of my antibodies. There is also insulinomas that can produce too much insulin which will cause hypoglycemia.
I tried us med and had a very bad experience. I won’t fill your comments with my rant but overall it was pretty bad. Uncaring people who turned me into a number. Missed my secondary insurance and tried to charge me a lot more than they should have. I even emailed my complaint to them and never even got a reply. I had already had my doctor fax them the paperwork which was a job in itself. Now I’m shopping around for a company to replace them. After I find one I’ll then have to go back through the paperwork job. I realize you’ve had a good experience with us med but not me. I picked them out because they seemed to be the best but they let me down big time.
Carole Ne says
I would like to know why a monitor cannot be purchased by a person on their own?
Christel Oerum says
I believe you can buy it cash, so without insurance
Hi it is not possible to buy it without prescription.. I am type 2 , tried 3 years .. still not able buy it with my own cost 🙁
Can your doctor give you the prescription and then you can self pay?
Christel Oerum says
Yes, in the US that’s an option
love your bulletin however, I’m a little bewildered why you don’t talk about Eversense CGM? I think you know it’s the most reliable with MARD’s reliably in the 8 territories and furthermore the most noteworthy precision in hypoglycemic occasions. Far superior to Dexcom and Abbott. This is distributed information yet as a T1D, I really wore a Dexcom G6 while on Eversense and observed my low sugar occasions and Eversense was speedier to show my drop than Dexcom 9 out of multiple times. Diabetics should know all decisions accessible to them.
Christel Oerum says
We do have content covering Eversense on the website. I can’t cover it from a personal perspective as I haven’t tried it, so we have others writing about it. It’s a great product and I can’t wait to see the 180-day sensor be approved in the US
Christel, love your newsletter but I’m a little perplexed why you don’t speak about Eversense CGM? I think you know its the most accurate with MARD’s consistently in the 8 range and also the highest accuracy in hypoglycemic events. Much better than Dexcom and Abbott. This is published knowledge but as a T1D, I actually wore a Dexcom G6 while on Eversense and monitored my low sugar events and Eversense was quicker to show my drop than Dexcom 9 out of 10 times. Diabetics should know all choices available to them.
Christel Oerum says
We do talk about Eversense on the website and they have even been the sponsor for one of our challenges. Now that it’s commercially available again in the US I think we’ll see more people exploring the idea, especially once the 180-day sensor gets FDA approval.
I tend to focus more on Dexcom and Libre as they are more widely used and generally available in most countries, but you’re right we shouldn’t overlook it
Agreed 🙂 Thanks for your feedback and regardless of which 1 you choose I certainly would be lost without my CGM.
Seth Antill says
I’ve been a type 1 diabetic since 2001 I’ve been trying to get a continuous glucose monitor for the last 6 years and virtually impossible and the only reason I can figure out is because of Medicaid requirements. I’ve been to many Walmarts and seeing the continuous glucose monitor system on back shelves and have walked in there with hundreds of dollars in my pocket trying to purchase one and they literally tell me they cannot help you have to have a prescription. Frustrating thing for me is couple days ago I just got out of the ER for hypoglycemia with a seizure and if I asked one of the ER doctors to give me some pain medication for my headaches from the seizure! I could get that in the blink of an eye. But any assistance with a machine that would help reduce the interaction with paramedics and firemen that probably come to my house two or three times a month. Is just worth it, not from a saving money perspective. Sorry for venting but it is frustrating being 43 and being a diabetic for over 21 years. And I have pretty much given up on being blesed with CGM capabilities.
Christel Oerum says
I’m sorry to hear that, that’s frustrating!
You do need a prescription for any of the CGMs available. But if you have that they should be able to sell you one cash. I would start with the prescription and then just bring that to the pharmacy. Your primary care doctor should be able to write that for you.
I love my Dexcom G 6. And when USMed took over from Dexcom ordering was made easy.
I travel a lot, and having a continuous monitor has been a life changer
Christel Oerum says
I’m so happy to hear that! It works well for me too