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The purpose of this bulletin is to inform the provider community of the following coverage update per Item 288.OOOOO.1 of the 2025 Appropriation Act:

Effective July 1, 2025, the Department of Medical Assistance Services shall amend the State Plan for Medical Assistance to authorize coverage for a continuous glucose monitor (CGM) and related supplies for the treatment of a Medicaid enrollee under the Medicaid medical and pharmacy benefit if the enrollee: (i) has been diagnosed with diabetes by his or her primary care physician, or another licensed health care practitioner authorized to make such a diagnosis; (ii) is being treated with insulin; and/or (iii) has a history of problematic hypoglycemia; (iv) the enrollee's treating practitioner has concluded that the enrollee (or enrollee's caregiver) has sufficient training using the CGM prescribed as evidenced by providing a prescription; and (v) the CGM is prescribed in accordance with the Food and Drug Administration indications for use.

To qualify for continued coverage, the Medicaid enrollee must participate in follow-up care with his or her treating health care practitioner, in-person or through telehealth, at least once every six months during the first 18 months after the first prescription of the continuous glucose monitor for the recipient has been issued, to assess the efficacy of using the monitor for treatment of diabetes. After the first 18 months, such follow-up care must occur at least once every 12 months.

This coverage extends to both fee-for-service (FFS) and manage care coverage. 

For FFS medical claims, please contact Acentra Health for CGM authorization. For FFS pharmacy claims, contact Prime Therapeutics for CGM authorizations. For managed care, contact the respective managed care organization (MCO) for authorization.