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This message was sent June 3, 2024 to MCT2D participating physician organization (PO) administrative leads.
We have very exciting news to share with you regarding prescription coverage for Continuous Glucose Monitors (CGM) for commercial Blue Cross Blue Shield of Michigan and Blue Care Network members. BCBSM/BCN has reviewed their recent CGM policy changes and has decided to expand their coverage for commercial members who are prescribed CGM by either an MCT2D OR Provider Delivered Care Management (PDCM) participating physician (see definition of “MCT2D participating physician” below).
Effective June 1st, 2024, the following criteria NO LONGER APPLY to MCT2D (or PDCM) participating physicians who prescribe CGM for BCBSM/BCN commercial members with a diagnosis of either type 1 or type 2 diabetes under either the pharmacy or medical benefit:
- Member uses insulin (Please note, prior insulin claims will still qualify members for pharmacy point-of-sale coverage. Members prescribed CGM by either a MCT2D or PDCM-participating physician aren’t required to have a prior insulin claim for pharmacy point-of-sale coverage), OR
- Member has a history of problematic hypoglycemia, OR
- Member has a diagnosis of diabetes while pregnant and experiences post-prandial hyperglycemia
Please note: The changes outlined in this communication don’t apply to Medicare beneficiaries.
Download a one-page guide to the BCBSM/BCN CGM policy change
There are multiple phases to this approach for CGM covered under the pharmacy benefit and durable medical equipment (DME) benefit for BCBSM/BCN commercial members:
Pharmacy Benefit
Applicable Dates | Impacted Physicians | Requested Action for MCT2D (or PDCM) Participating Physicians |
6/1/2024 – 6/30/2024 | Current MCT2D (or PDCM) participating physicians | Submit an electronic prior authorization (ePA) through an online ePA platform (ex: CoverMyMeds). The ePA submission must include a comment to attest that the prescriber is a MCT2D (or PDCM) participating physician for PA approval. BCBSM will approve the CGM prior authorization for 60 days. This will allow sufficient time for BCBSM to add the MCT2D (or PDCM) participating physician to the approved list of physicians who are eligible for claim payment at the pharmacy without prior authorization starting July 1, 2024. Once the member’s prior authorization expires after the 60-day period, they will have their CGM covered at pharmacy point-of-sale without prior authorization. |
Effective 7/1/2024 | Current MCT2D (or PDCM) participating physicians | No action needed. BCBSM/BCN commercial members prescribed CGM by a MCT2D (or PDCM) participating physician are exempt from prior authorization for coverage as these physicians will be added to the approved list of physicians who are eligible for claim payment at the pharmacy without prior authorization starting July 1, 2024. |
9/1/2024- 10/15/2024 | Newly joining MCT2D [or PDCM] primary care physicians (newly recruited practice or newly eligible for VBR) as of September 1, 2024 | Submit an electronic prior authorization (ePA) through an online ePA platform (ex: CoverMyMeds). The ePA form will include a question that will ask the submitter to attest that the prescriber is a MCT2D (or PDCM) participating physician for PA approval. BCBSM will approve the CGM prior authorization for the standard duration of 365 days if the ePA submitter attests “Yes” to the physician’s participation in either the MCT2D or PDCM program. This will allow sufficient time for BCBSM to add the MCT2D (or PDCM) participating physician to the approved list of physicians who are eligible for claim payment at the pharmacy without prior authorization starting October 15, 2024. Once the member’s prior authorization expires after the 365-day period, they will have their CGM covered at pharmacy point-of-sale without prior authorization, as long as the prescribing physician is still participating in either the MCT2D or PDCM program. These statements do not apply to VBR-eligible physicians participating in either the MCT2D (or PDCM) program prior to September 1, 2024, as these physicians will be eligible for claim payment at the pharmacy without prior authorization starting July 1, 2024, as mentioned above. |
Effective 10/15/2024 | Newly joining MCT2D [or PDCM] primary care physicians (newly recruited practice or newly eligible for VBR) as of September 1, 2024 | No action needed. BCBSM/BCN commercial members prescribed CGM by a MCT2D (or PDCM) participating physician are exempt from prior authorization for coverage as these physicians will be added to the approved list of physicians who are eligible for claim payment at the pharmacy without prior authorization starting October 15, 2024. |
Durable Medical Equipment (DME)
Please note: Prior authorization is still required under the medical (DME) benefit; however, BCBSM/BCN commercial members prescribed CGM by MCT2D (or PDCM) participating physicians are exempt from meeting clinical criteria for prior authorization approval. The contracted DME supplier, Northwood, Inc., will submit the prior authorization on behalf of the prescribing physician.
Applicable Dates | Impacted Physicians | Requested Action for MCT2D (or PDCM) Participating Physicians |
6/1/2024 – 8/31/2024 | Current MCT2D (or PDCM) participating physicians | Physician must include a comment on the prescription to attest that they are participating in the MCT2D OR PDCM program for prior authorization approval for members with a diagnosis of type 2 diabetes that fill a CGM for the first time (new users). |
Effective 9/1/2024 | Current MCT2D (or PDCM) participating physicians | A prior authorization will still need to be submitted with a CGM order. PA will be auto-approved based on physician NPI number. |
9/1/2024-10/15/2024 | Newly joining MCT2D primary care physicians (newly recruited practice or newly eligible for VBR) as of September 1, 2024 | Physician must include a comment on the prescription to attest that they are participating in the MCT2D OR PDCM program for PA approval for members with a diagnosis of type 2 diabetes that fill a CGM for the first time (new users). |
Effective 10/15/2024 | Newly joining MCT2D primary care physicians (newly recruited practice or newly eligible for VBR) as of September 1, 2024 | A prior authorization will still need to be submitted with a CGM order. PA will be auto-approved based on physician NPI number. |
Definition of MCT2D participating physician
“MCT2D participating physician” is defined as a physician whose practice is participating in MCT2D and and who is earning MCT2D VBR.
The MCT2D coordinating center has submitted lists to BCBSM of physicians who are earning the 2023 MCT2D PCP VBR (effective dates 09/01/2023 – 03/31/2024) and 2024 MCT2D Specialist VBR (effective dates 03/01/2024 – 02/28/2025).
Please note that members prescribed CGM by Advanced Practice Providers (APPs) attributed to physicians participating in the MCT2D (or PDCM) program are not exempt from clinical coverage requirements. The CGM product must be ordered (i.e., prescribed) by the MCT2D (or PDCM) participating physician to exempt the member from meeting clinical criteria for coverage.
Steps for processing the MCT2D physician list
A list of physicians who can prescribe CGMs between now and June 30th with a prior authorization attesting to participation in MCT2D is now available to you on the MCT2D Admin Portal, as a tab called “Physicians Exempt from CGM Criteria” with an ability to export. Please distribute this list to your MCT2D practices and inform them of who will be able to prescribe CGMs under these revised criteria.
As mentioned above, effective July 1st, BCBSM/BCN commercial members prescribed CGM by a physician on this list won’t require a prior authorization for coverage under the pharmacy benefit. Additionally, effective September 1st, BCBSM/BCN commercial members prescribed CGM by physicians on this list will have their prior authorization requests automatically approved under the medical (DME) benefit.
In the summer, as in previous years, you will be provided with a list of PCPs that will begin earning MCT2D PCP VBR, effective annually on September 1st, 2024 – August 31st, 2025. The MCT2D coordinating center expects you to review and approve this list before it is finalized (failure to meet this expectation may mean some physicians will miss earning VBR effective 9/1/2024 and will not be able to prescribe CGMs under these new criteria for the future effective date). Any MCT2D PCPs earning MCT2D VBR as of 9/1 (including new recruits), will be eligible to prescribe CGM under these revised criteria.
Support
MCT2D and BCBSM will host drop-in, optional “office hours” this Monday, June 3, 2024 from 3pm-3:30 and Thursday (June 6th) from 4pm-4:30. We will send you a calendar invite to each call shortly and will generate a list of FAQs based on the questions we receive.
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ccteam@mct2d.org
Support for The Michigan Collaborative for Type 2 Diabetes (MCT2D) is provided by Blue Cross Blue Shield of Michigan as part of the BCBSM Value Partnerships program.
Although Blue Cross Blue Shield of Michigan and MCT2D work collaboratively, the opinions, beliefs and viewpoints expressed by the author do not necessarily reflect the opinions, beliefs and viewpoints of BCBSM or any of its employees.