For millions of people managing diabetes, Continuous Glucose Monitoring (CGM) systems like FreeStyle Libre and Dexcom have become essential tools. These devices help track blood sugar levels in real time, eliminating the need for frequent fingersticks. However, the cost of CGMs can be a major concern, with some patients paying hundreds of dollars per month out-of-pocket. The good news is that there are several insurance coverage options for CGM systems that can significantly reduce costs.
Take Lisa, a 38-year-old mother with Type 1 diabetes, who was initially denied coverage for her CGM because her insurance provider required additional documentation. She assumed she had to pay the full price—until she discovered that a prior authorization from her doctor and a better understanding of her plan’s benefits could drastically lower her expenses. With the right approach, Lisa’s insurance plan now covers 80% of her CGM costs, making diabetes management much more affordable.
If you or a loved one relies on a CGM, understanding the insurance coverage options for CGM systems can help you cut costs and maximize your benefits. In this guide, we’ll walk you through five key ways to save money, whether you’re covered by private insurance, Medicare, or Medicaid.
1. Understand Your Health Insurance Plan
The first step in saving money on a CGM system is to fully understand your health insurance plan and how it covers diabetes management tools. Not all plans are the same, and some may have specific requirements before covering CGMs.
Deductible, Copay, and Coinsurance
Most insurance plans include a deductible, which is the amount you must pay before your insurer begins covering expenses. For example, if your deductible is $1,500 and you haven’t spent that amount yet on medical care, you may have to pay full price for your CGM until the deductible is met.
Once you reach your deductible, your copay (a fixed dollar amount) or coinsurance (a percentage of the cost, typically 10% to 30%) applies. This means you could end up paying only a fraction of the total CGM cost.
Coverage Tiers: Preferred vs. Non-Preferred Brands
Insurance providers often categorize medical devices into preferred and non-preferred brands. Preferred brands (like Dexcom or FreeStyle Libre) often have lower copays compared to non-preferred ones. If your CGM system is classified as non-preferred, you may pay significantly more.
Prior Authorization and Medical Necessity
Some insurance plans require prior authorization before covering a CGM. This means your doctor must submit paperwork proving that a CGM is medically necessary. Common reasons insurers approve CGM coverage include:
- Frequent hypoglycemia or hyperglycemia episodes
- A history of hospitalization due to blood sugar fluctuations
- The need for insulin therapy
If your prior authorization request is denied, you can appeal the decision by providing additional medical documentation.
2. Check Medicare and Medicaid Coverage for CGMs
If you have Medicare or Medicaid, you may be eligible for full or partial CGM coverage. However, coverage varies depending on specific program guidelines and state policies.
Medicare Coverage for CGM Systems
Medicare Part B covers CGM systems for qualifying beneficiaries. To be eligible, you must:
- Have Type 1 or Type 2 diabetes and require insulin therapy
- Test blood sugar levels four or more times daily
- Have a doctor’s prescription proving the medical necessity of a CGM
Medicare typically covers 80% of CGM costs, leaving 20% as an out-of-pocket expense. If you have a Medicare Supplement Plan (Medigap) or a Medicare Advantage Plan (Part C), you may get additional financial assistance that reduces or eliminates the remaining balance.
Medicaid Coverage: State-by-State Variations
Medicaid coverage for CGMs depends on your state’s Medicaid program. Some states provide full coverage for low-income individuals, children, and seniors, while others may limit coverage based on income or require additional medical documentation.
If you’re unsure whether your state’s Medicaid plan covers CGMs, you can:
- Contact your state’s Medicaid office
- Ask your healthcare provider for guidance
- Check if your doctor can submit an appeal for coverage
3. Use an HSA or FSA to Pay for CGMs Tax-Free
If your insurance only partially covers a CGM or requires a high deductible, using an HSA (Health Savings Account) or FSA (Flexible Spending Account) can significantly reduce out-of-pocket costs.
Health Savings Account (HSA) Benefits
An HSA is a tax-free savings account designed for medical expenses. You must have a high-deductible health plan (HDHP) to qualify. Contributions are tax-deductible, and any unused funds roll over each year, making it an excellent long-term option.
Flexible Spending Account (FSA) Advantages
An FSA is a pre-tax account offered by employers to cover healthcare expenses. The main difference from an HSA is that FSA funds expire at the end of the year if not used. However, it’s a great way to use tax-free dollars to pay for CGMs.
Both accounts help reduce taxable income while covering CGM expenses.
4. Check Manufacturer Discounts and Copay Assistance Programs
Many CGM manufacturers offer discount programs to reduce costs for insured patients.
Manufacturer Assistance Programs
- Dexcom Patient Assistance Program – Provides financial relief to eligible patients.
- FreeStyle Libre Savings Card – Lowers copay costs for people with commercial insurance.
If your insurance doesn’t fully cover a CGM, these programs can cut costs by up to 50%.
Pharmacy vs. Durable Medical Equipment (DME) Supplier Coverage
CGMs are often covered either through pharmacy benefits or as durable medical equipment (DME). If your insurance classifies CGMs as DME, ordering through a medical supplier may be cheaper than purchasing from a pharmacy.
5. Work With a Medical Supply Company to Maximize Coverage
Insurance paperwork and claims can be time-consuming and confusing. A medical supply company can help by:
Verifying Insurance Coverage
Medical supply providers check what’s covered under your insurance plan and identify cost-saving options.
Handling Prior Authorizations and Appeals
If your insurance requires prior authorization, the supplier will coordinate with your doctor to ensure approval.
Direct Billing for Medicare, Medicaid, and Private Insurance
A medical supply company can handle direct billing, ensuring you pay the lowest possible amount for your CGM system.
How Can Aptiva Medical Help You?
At Aptiva Medical, we specialize in helping patients access CGM systems affordably by handling insurance verification, paperwork, and billing. Our team makes the process fast and hassle-free, so you can focus on your health.
Visit us at: 5249 NW 33rd Ave, Fort Lauderdale, FL 33309
Call us today at: (800) 310-2568
Our Services Include:
- Checking insurance benefits for FreeStyle Libre and Dexcom CGMs.
- Handling prior authorizations to speed up the approval process.
- Finding the lowest-cost options based on your insurance plan.
Don’t let high costs stop you from managing your diabetes. Call Aptiva Medical today and start saving on your CGM system!
Frequently Asked Questions
Can individuals with Type 2 diabetes who are not on insulin therapy get insurance coverage for CGM systems?
Yes, Medicare now covers CGM systems for individuals with Type 2 diabetes who experience problematic hypoglycemia, even if they are not on insulin therapy.
Are there continuous glucose monitors available over-the-counter for non-insulin users?
Yes, devices like the Dexcom Stelo are FDA-cleared for over-the-counter use, specifically targeting individuals with Type 2 diabetes who do not use insulin.
Does Medicaid cover CGM systems for children with diabetes?
Yes, all children under 21 enrolled in Medicaid are eligible for CGM coverage through the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) program.
Are implantable CGM systems covered by insurance?
Coverage varies by insurer, but many commercial insurance plans cover FDA-approved implantable CGM systems like the Eversense 365.
