Continuous Glucose Monitoring Systems Coverage Transition

Tuesday, July 21, 2020

Effective July 1, 2020, coverage of therapeutic Continuous Glucose Monitoring (CGM) products is transitioning from the Durable Medical Equipment (DME) Program to the Outpatient Pharmacy Point of Sale (POS) Program. The products will be included on the North Carolina Medicaid and NC Health Choice Preferred Drug List (PDL)

To help ensure a smooth transition, prior authorizations (PAs) obtained through the DME program for therapeutic CGM products that are active at the time of transition will be converted to pharmacy PAs in NCTracks. 

  • Coverage of non-therapeutic CGM products will not transition and will remain under the DME program. 
  • Billing for these supplies should continue through the DME program. 

As of July 1, 2020, when DME providers submit PAs or claims for CGM products, they must include documentation of the brand and model of CGM products supplied. This documentation will help prevent creation of duplicate PAs or paying duplicate claims for therapeutic CGM products.

Effective July 1, 2020, new and existing therapeutic CGM users must obtain their CGM supplies from an enrolled NC Medicaid pharmacy provider of their choice. All claims for therapeutic CGM products will be processed through pharmacy POS billing. 

  • All therapeutic CGM products will require an active and valid prescription at the filling pharmacy on file. 
  • The PDL Preferred therapeutic CGM products will be the Dexcom G5 and G6.  
  • The PDL Non-preferred therapeutic CGM product will be the Freestyle Libre. 

Pharmacies are encouraged to order sufficient inventory of therapeutic CGM products to satisfy beneficiary demand during this transition.

Updated State Maximum Allowable Cost (SMAC) rates effective July 1, 2020 for the appropriate therapeutic CGM National Drug Codes (NDCs) are:

Description

NDC

SMAC

DEXCOM G5-G4 SENSOR KIT       

08627005104

$82.17

DEXCOM G6 SENSOR

08627005303

$111.66

DEXCOM G6 TRANSMITTER

08627001601

$237.50

DEXCOM G6 RECEIVER

08627009111

$365.00

FREESTYLE LIBRE 14 DAY READER

57599000200

$70.00

FREESTYLE LIBRE 14 DAY SENSOR

57599000101

$54.43

 

Contact

NCTracks Contact Center: 800-688-6696