This content originally appeared on diaTribe. Republished with permission.
By April Hopcroft
Key takeaways:
- Verify your CGM coverage and costs with your insurance plan and healthcare provider. Use the ADCES tool for detailed coverage information.
- Medicare provides broad CGM coverage with some out-of-pocket costs. Medicaid coverage varies by state. People who are on both Medicare and Medicaid have no out-of-pocket expenses.
- Most commercial insurers cover CGMs for type 1 diabetes and for people with 2 diabetes on multiple daily injections or insulin pumps. Coverage specifics vary by insurer and state.
So you’ve decided to get a continuous glucose monitor (CGM). You’ve read up on all the models, familiarized yourself with the newest features, and are ready to take the next step.
However, a challenge awaits: Navigating insurance coverage.
As a starting point, be sure to check with your insurance plan to understand what coverage you may have and what your out-of-pocket costs might be.t. It’s a good idea to speak with your healthcare provider about insurance coverage, too. Your provider’s office may have a specific staff member whose job is to help people navigate insurance coverage.
You can check out the Association of Diabetes Care and Education Specialists (ADCES) CGM insurance coverage tool. Enter the name of your insurance, the type of plan you have, and your state of residence to get a summary of insurance coverage for CGMs.
CGM coverage if you have type 1 diabetes
CGM is generally covered for people with type 1 diabetes, regardless of type of insurance.
Medicare and Medicaid coverage
The majority of people in the US diagnosed with diabetes get insurance coverage through Medicare or Medicaid, according to Bruce Taylor, senior director of government affairs and market access at Dexcom.
Medicare and Medicaid are government insurance programs. Medicare is a nation-wide program that provides health coverage to people ages 65 and older. Medicaid is a joint federal and state program that provides health coverage to people with limited income and resources.
Medicare also provides health coverage to some people under age 65 with certain disabilities (such as kidney disease requiring dialysis or a transplant) who receive Social Security disability benefits, regardless of income level.
Medicare provides broad coverage of CGM, while Medicaid coverage varies by state.
Medicare coverage provides access to the following CGMs:
- FreeStyle Libre 14-day, Libre 2, and Libre 3 – provided you use the readers to review glucose data on some days each month.
- Dexcom G6 and G7
- Guardian 3 and Guardian 4 (when used with an insulin pump system)
- Note that the Guardian Connect CGM-only system is not covered by Medicare because it does not include a durable receiver to meet Medicare benefit requirements.
- Eversense E3 implantable sensor
After meeting the yearly Part B deductible (for medical equipment coverage), people with Medicare usually pay 20% of the total cost out of pocket.
Medicaid coverage varies from state to state, as do the eligibility requirements to qualify for Medicaid – see if you qualify here.
As of May 2024, 48 states and Washington, D.C. provide some amount of CGM coverage for Medicaid beneficiaries. Currently, 29 of these states cover CGM for people who use insulin through a pharmacy benefit (instead of medical benefit), which makes it easy to get a CGM at a local pharmacy; typically, there is no out of pocket cost.
People who are dual eligible – meaning they are enrolled in both Medicare and Medicaid – have no out of pocket expenses for a CGM.
Commercial insurance through an employer
Commercial insurance, often called private insurance, is the most common form of health insurance in the US. Most commercial insurers (such as Aetna, Blue Cross Blue Shield, Cigna, Kaiser, and UnitedHealthcare) cover all of the major CGMs for people with type 1 diabetes.
According to Abbott, most people with private or commercial insurance pay less than $40 per month for their FreeStyle Libre CGM sensors.
Taylor, from Dexcom, noted that most commercially insured users have a $0 copay for their Dexcom CGM. Otherwise, the co-pay is usually $20 or less per month when coverage is issued as a pharmacy benefit and combined with savings from Dexcom.
CGM coverage if you have type 2 diabetes
CGMs are typically covered for people with type 2 who are taking multiple daily injections of insulin, use an insulin pump, or have had severe hypoglycemia (low blood sugar).
One challenge that could come up is a prior authorization, which means your healthcare provider or device company has to get specific approval from your health insurance company to pay for the CGM.
If for any reason your insurance provider decides to deny coverage for a CGM, know that you can appeal and formally ask them to reconsider their decision.
Medicare and Medicaid coverage
In 2023, Medicare expanded coverage of CGMs to include people with type 2 diabetes who take any type of insulin, as well as type 2s who are not taking insulin but have a history of hypoglycemia. Since Medicare is a national program, this coverage applies throughout the US.
Medicaid coverage varies from state to state. As of 2023, many states provide Medicaid coverage for people with type 2 diabetes.
All children in the US under the age of 21 enrolled in any Medicaid program can access a CGM through the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) program.
Medicaid programs generally require a prior authorization from a healthcare provider to receive CGM coverage. You may need to meet certain eligibility criteria, such as proving a diabetes diagnosis and showing that you regularly see an endocrinologist, for instance.
Commercial insurance through an employer
CGM coverage varies depending on your insurance plan, so be sure to check with your individual plan for specific information.
- Cigna covers CGM for type 2 for anyone on multiple daily injections, long-acting basal insulin, or an insulin pump. Cigna’s coverage includes the Senseonics implantable sensor.
- Aetna covers CGM for type 2 when on multiple daily injections or insulin pump, and not meeting glycemic targets OR experiencing hypoglycemia or hypoglycemia unawareness.
- UnitedHealthcare covers CGM for adults with type 2 diabetes who use insulin.
- Blue Cross Blue Shield covers CGMs for adults with type 2 who use insulin therapy; note that coverage varies by state. In California, for instance, CGMs may be covered under pharmacy benefits (with a prior authorization) or through the medical benefit at certain durable medical equipment (DME) companies.
- Kaiser Permanente covers CGM for adults with type 2 diabetes who are on multiple daily injections or use an insulin pump.
Coverage through durable medical equipment (DME) suppliers
Note that for certain insurance plans, you may be eligible for CGM through a durable medical equipment provider (such as Byram Healthcare or Advanced Diabetes Supply) through your insurance, as CGMs are considered durable medical equipment and are not covered by the pharmacy benefit. If this is the case, ask your healthcare provider to submit a referral for CGM to the DME provider.
Other ways to obtain a CGM
Without insurance, CGMs – including the sensor, transmitter, and receiver – can cost $1,000 to several thousand dollars per year.
Often you can find coupons for specific pharmacies on GoodRx.com to further lower the cost. Many people find the Freestyle Libre CGMs to be the most affordable options, especially when paying out of pocket.
The typical out of pocket cost for common CGMs are:
- FreeStyle Libre 2 and 3 – about $140 to $150 per month
- Dexcom G6 and G7 – about $170 to $180 per month
- Guardian Sensor 3 – about $180 for a five week supply
- Guardian 4 – about $280 for a five week supply
- Eversense E3 – about $1,500 to $1,600 per year
If you are still unable to access CGM, there are a few other options. Your healthcare team can offer you a professional CGM to wear for a short period of time (usually two weeks) as a way to learn how to increase your time in range. Alternatively, you could join a clinical trial for diabetes medications or technology, many of which offer free CGMs for the duration of the study.
Lastly, there are many different patient assistance programs (PAPs) and savings programs available online.
Dexcom CGMs
Dexcom offers a free insurance benefits check to see if you have CGM coverage – find more information in the Dexcom Savings Center.
If you have a high copay or plan to pay out of pocket, Dexcom offers a savings program, which can help you save over 50% of the standard monthly cash price.
Dexcom also offers a patient assistance program to US residents who meet specific poverty line requirements and eligibility criteria.
FreeStyle Libre CGMs
If you qualify for the MyFreeStyle program, you can access a free sensor for a two week trial period.
For people without CGM coverage, Abbott’s Consumer Access Program ensures you pay no more than $75 per month. This program is for people with commercial insurance or cash-paying customers and does not apply to government insurance programs like Medicare or Medicaid.
Guardian 3 and 4 sensors
If you don’t have insurance coverage for your prescribed CGM, you may be eligible for discounts from Medtronic. To qualify, you must use multiple daily injections or use an insulin pump, have no insurance coverage for Medtronic CGM, and call Medtronic to confirm your eligibility.
The discount caps transmitter cost up to $180 per transmitter for a 12-month period and $60 per box of sensors for each month.
Eversense implantable CGM
Senseonics offers a patient assistance program for the Eversense implantable CGM, which has the potential to save users up to $1,200 per year.
Senseonics recently expanded the program to include more commercially insured people with diabetes. Through this program, eligible people pay only $99 out of pocket for an unlimited number of 6-month Eversense E3 systems. This means you would pay an average of $16.50 per month, amounting to less than $200 out of pocket costs for an entire year of CGM (excluding the costs of insertion and removal).
The bottom line
Understanding insurance coverage for your CGM can feel like a daunting task. Fortunately, broad Medicare and commercial insurance coverage for CGM exists for people with type 1 diabetes. Medicare and many commercial insurance plans also cover CGMs for people with type 2 diabetes who use insulin.
If you don’t have insurance, CGM companies offer patient assistance programs and other discount programs to make CGMs more affordable.
“In general, cost shouldn’t be a barrier if you have insurance coverage,” Taylor said. “The biggest challenge is many times people don’t understand what benefits they qualify for.”
If you have questions about CGM coverage, consult your healthcare team to understand your options.
*Editor’s note: This article is not a comprehensive list of all insurance plans. It was last updated in May 2024.
